Owner Trained Service Dog Application

Work
Do you work?*

Yes, full timeYes, part timeNo
If you work, do you want your dog to go to work with you?

YesNo
Have you discussed bringing your Service Dog to work with your employer?

YesNo
Please supply us with any information regarding your work environment that may be helpful

Transportation
What type of transportation do you use? If you use public transportation please be specific.*
If you drive your own car, what type of car is it?

Veterinary Information
Please supply us with information on your current veterinarian or on the veterinarian you intend to use if you receive a service dog.
Name

First NameLast Name
Hospital Name*
Phone Number*

Area CodePhone Number
Email*
example@example.com

Training

Training classes are done in Center Conway, New Hampshire.
Are you able to come to Center Conway weekly for training classes of a period one year?*
Please supply us with any other information regarding training process that you feel is relevant.

References
Please supply us with three references. Once we receive this form we will email the link to the Reference Form to each of your references. Please let them know that you have chosen them. Make them aware that they will be receiving a link from us via email.

You should choose your references carefully. Please do not select immediate family members like husbands, wives, children, mothers, or fathers. The best references are individuals who can speak without prejudice to your character in general, your capabilities, and your individual experiences with dogs if you have had dogs.
First Reference
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*

Area CodePhone Number
Email*
example@example.com
Second Reference
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*

Area CodePhone Number
Email*
example@example.com
Third Reference
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone*

Area CodePhone Number
Email*
example@example.com

Other
Is there any other information that you would like to add to your application?
Conditions
I understand that there is a $100 non-refundable processing fee to be mailed to ACTS, 2928 East Conway Road, Center Conway, NH 03813, and that this fee is non-refundable.*

Yes
I understand that ACTS reserves the right to conduct a background check.*

Yes
I understand that ACTS reserves the right to conduct a home visit or to utilize video conferencing as part of the application process.*

Yes
I understand that my application will not be considered complete until all parts of the application have been submitted, including: Application Form, Medical Form, three references, and the $100 processing fee. I understand that once my application is complete, a "Home Visit" or a "Face Time" interview will be conducted and that an evaluation of my dog will be conducted. I understand that the application committee will review my completed application, medical form, references, home visit/face time call. and determine if I will be a candidate for the Owner Trained Service Dog Program. I understand that I will not be considered until this process is complete.*

Yes
I understand that ACTS reserves the right to release me from the program at any time should my dog be deemed not suitable for service dog work or should it be deemed that I am not following the required standards of behavior as outlined by ACTS*

Yes
I understand that during the time I am training there may be unforeseen changes in the organization or in the industry that may result in the inability of ACTS to complete their services.*

Yes
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*

Clear
Please mail your application fee of $100 to:

ACTS
2928 East Conway Road
Center Conway, NH 03813

Your application for a service dog will not be complete until we have received all of the following:
1. Service Dog Application Form
2. Medical Form
3. Three References
4. Non-refundable application fee of $100
When you click the SUBMIT button, the final version of your form will be sent to A.C.T.S.

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