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Service Dog Application
Part A

All applicants for Service Dogs MUST complete forms A, B and C.

If you are in need of a Psychiatric/PTSC Service Dog, please complete forms A, B and C first, then continue to the section under Psychiatric/PTSD forms.

Date
Month
Day
Year
Date of Birth
Month
Day
Year
Gender
Male
Female
Multi-line address

Military Personnel Only:

List the type of dog that would be best for your current situation from the list below:

What is your disability?

A disability is any condition which makes it more difficult for a person to do certain activities or interact with the world around them. These conditions, or impairments, may be cognitive, developmental, intellectual, mental, physical, sensory, or a combination of multiple factors. Paws For Life USA service dogs, are custom trained to alert and assist people with their disabilities. We help those with Autism, Brain Injuries, Diabetes, Epilepsy, Hearing, Medical, Mental, Mobility, Neurological, Physical, Psychiatric, PTSD, Seizures, Vertigo and Visual impairments. Paws For Life USA trains Assistance dogs for in home use only, therefore not granted the full public access as is given for Service Dogs. We custom train dogs for all ages based on the individual and / or their care givers ability to work with the dog.

Please indicate the devices that you use:
Which of the following do you do most often:

Describe your physical strengths and abilities.

From 1-10. (Write a number from 1-10 in the space for each limb.)

1 being NO USE--------- 10 being FULL USE

Please rate: (On a scale of 1=Poor – to – 10=Normal)

Write the number between 1-10 in the space provided.

Do you use a word board?
Your Vision: Do you use corrective lenses?
Do you need?
Do you use?
Hearing Aid
ASL

How do you handle the following?

Routine Medications
By Yourself
Assisted
Provided by Others
Your finances & Checkbook
By Yourself
Assisted
Provided by Others
House cleaning
By Yourself
Assisted
Provided by Others
Meals
By Yourself
Assisted
Provided by Others
Getting Dressed
By Yourself
Assisted
Provided by Others
Shopping, Groceries
By Yourself
Assisted
Provided by Others
Personal Care
By Yourself
Assisted
Provided by Others
What personal attendants (including family members) do you use?
Please check limitations that apply to you:
Do any other members of your household have a physical or mental disability?
Yes
No
If you have an animal now, would you be willing to give up your present animal, if it cannot get along with a PFL USA dog?
Yes
No
If your present dog is not well-mannered, are you willing to have PFL USA train your dog in unison with your PFL USA dog?
Yes
No
Will it be difficult for you to to attend group classes at the PFL USA Training Center in Marietta, GA for an hour to hour and a half one day a week for as long as needed?
Yes
No
Will it be difficult for you to limit your calendar for the 30-day bonding period?
Yes
No
Will it be difficult for you to attend one on one obedience | task training classes?
Yes
No
Is there a reasonable expectation that your medical situation will allow you to use and benefit from your dog’s skills for 8 to 10 years?
Yes
No

Paws for Life USA recommends Service Dogs NOT be crated.

Do you agree that a PFL USA dog will spend most of their time with their handler at home AND at work, at school, and social events if he/she is certified for public access and that no Paws for Life USA dog will be left in a yard unattended.
Yes
No
Do you agree that a PFL USA Dog is not a family pet – he or she has a specific function in their handler’s life and minimal interaction with others except when given the free time command?
Yes
No
Do you understand that you and your dog are ambassadors for Paws for Life USA, as well as for the entire service dog industry and you will be expected to maintain your dog’s appearance and manners, as well as your handling skills?
Yes
No
Do you agree that a PFL USA dog cannot be allowed off leash except to perform a specific task for their handler? Exercise in a secure fenced area is permitted. Elimination must be done on leash to maintain relieving on command cue.
Yes
No

You must assume full responsibility as caretaker of your PFL USA dog, and commit to be in charge of their safety, health, and welfare.

Medical care – all care prescribed by your veterinarian and routine annual care as directed by PFL USA. (Copies of medical records must be sent to Paws for Life USA whenever services are provided. PFL USA will provide minimum requirements for care.)
Yes
No
Nutritional care – including use of a good quality dog food and maintaining your dog’s proper weight.
Yes
No
Daily exercise and play
Yes
No
That you assume full responsibility for maintaining appropriate training and behavior and updating your public access certification annually with Paws For Life USA. You must maintain identification for public access.
Yes
No
That you must assume full responsibility for cleaning up after your dog eliminates in public and for repairing any damage caused by your dog.
Yes
No
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APPLICANT SIGN HERE

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IF YOU ARE A MINOR, YOUR PARENT OR GUARDIAN SIGNS HERE.

Return Part A of the Client Application by hitting Submit below OR print and send with your Part B & C to: Paws for Life USA P.O. Box 72016, Marietta, GA 30007-2016 If you have questions, call us at (770)-402-0297

Verification

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