MARK-9 Application
Handler's Name
*
First Name
Last Name
Handler's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Handler's Phone
*
-
Area Code
Phone Number
Handler's Email
*
example@example.com
K-9 Name
*
Breed
*
Function (select all that apply)
Cadaver
Explosive Detection
Narcotics Detection
Patrol
Search and Rescue
Other
Date of Birth (best guess if unknown)
*
/
Month
/
Day
Year
Date
Department Served
*
Years in Active Service
*
Reason for retirement:
*
Pertinent Medical History and care required
Current Medications (Name, Dose, Frequency)
For what care is the current funding being requested for? (Check all that apply)
Annual Exam
Refill of Medications
Injury
Illness
Other
Annual Exam Due date
-
Month
-
Day
Year
Date
Medications Needed
Describe Injury
Describe Illness
Upload MARK-9 Certifying Statement. This form can be downloaded below. If you wish to submit your application without uploading now, you can. The MARK-9 Certifying Statement can be sent via fax or email once completed.
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How did you hear about MARK-9?
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