Reference Form

ACTS - Assistance Canine Training Services
2928 East Conway Road
Center Conway, NH 03813
603-383-2073
info@assistancecanine.org

IMPORTANT INSTRUCTIONS: Please read carefully

Please use your TAB key to move on to the next entry box.

This form MUST be filled out in one session. If you leave the session, the form will NOT be saved.

Applicant

Today's Date*

Date

Applicant Name*

First NameLast Name

The above applicant has applied for a service dog from Assistance Canine Training Services. We thank you for taking the time to answer the following questions. We appreciate your thoughtful and honest response.

Your Information

Your Name*

First NameLast Name

Your Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone *

Area CodePhone Number

Email*

example@example.com

Your Relationship to the Applicant*

How Long You Have Known the Applicant*

Medical Information

Please complete the below medical information if the applicant has a medical or psychiatric disability.

How does the applicants disability affect the applicants daily functioning?

Would any of the applicants medical conditions affect his/her ability to handle or care for a dog?

Do you feel the applicant has the physical ability to handle and care for a dog?*

General Information

Tell us about the applicant. *

Do you think the applicant would benefit from a dog? Please explain.*

Does the applicant have any other dogs?*

yesno

If yes can you please tell us how the applicant cares for and interacts with his/her dog/s.

If the applicant has other dogs, are they well cared for and vetted when needed?

If the applicant has other dogs, are they trim and free from excess weight?

If the applicant has other dogs, do any of them live out side? If so, please explain.

Does the applicant have any other animals? If so are they well cared for?

Please explain in detail if you have any concern about the placement of a dog with this person.*

Additional comments

I acknowledge that by submitting my name and signing below, that all the above information is accurate.

Name*

First NameLast Name

Please Sign and Submit*

When you click the SUBMIT button, the final version of this form will be sent to ACTS.

Reference Form for Service Dog Applicants