My Service Dog, Inc
PO Box 706
Montgomery, TX 77356
(713) 703-6924
www.myservicedog.com

Please print and fill out all information in the Service Dog Application Form and a letter from your doctor stating
that you are in need of a Service Dog and mail to My Service Dog Inc. with a $50.00 check or money order
for processing. Allow two to three weeks for completion.

Applicant Name ___________________________________________________________________

DOB ________________________ Age __________________________ M/F _________________

Address _________________________________________________________________________

City ________________________________________ State _________ Zip ___________________

Phone _______________________________ Phone 2 ____________________________________

Cell ________________________________ Cell 2 _______________________________________

Fax _____________________________________________________________________________

Email ___________________________________________________________________________

_____ Married _____ Single _____Other _______________________________________________

Spouse Name ____________________________________________________________________

Employer ________________________________________________________________________

Position/Title _____________________________________________________________________

Address _________________________________________________________________________

City ______________________________________ State _______ Zip _______________________

Phone ________________________________________ Ext. _______________________________

There how long? ______________ Contact Name _________________________________________

If Applicant is a minor, please have parent/guardian complete form:

Parent/Guardian Name _____________________________________________________________

Address _________________________________________________________________________

City _________________________________________ State ________ Zip ___________________

Phone __________________________________ Phone 2 _________________________________

Cell ____________________________________ Other ___________________________________

Email ___________________________________ Other ___________________________________

_____ Married _____ Single _____Other _______________________________________________

Spouse Name ____________________________________________________________________
Employer ________________________________________________________________________

Position/Title _____________________________________________________________________

Address _________________________________________________________________________

City _____________________________________ State _______ Zip ________________________

Phone ________________________________________ Ext. _______________________________

There how long? ___________ Contact Name ____________________________________________

Please list all children in the household:

Name _______________________________________________ M/F ___________ Age _________

Medical History of Applicant:

Medical Diagnosis:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Age of onset: _________________________________________________________________________

Years with disabilities: __________________________________________________________________

All Physical Challenges due to disability:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Do you have a caregiver or medical attendant?
If so, how often do they come and give medical attention and what do they do:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Do you use a cane, walker or wheelchair? Please describe in detail: Yes/No
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Do you drive? If so what make of vehicle:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Are you an outdoor person or indoor person? Please describe all your activities and hobbies:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Do you participate in rehabilitation or therapy? Please describe:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Service Dog Requirements:

Type of dog you applying for: Service Mobility Hearing Physic. Therapy

Would your Service Dog accompany you everywhere? Yes/No

What qualities do you need in a Service Dog?
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

What tasks do you need in a Service Dog?
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Could you provide the dog with veterinary care, heart worm preventive, flea control, grooming,
exercise and feeding?
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

If you are unable to do the daily tasks of feeding and care of the Service Dog, who would be the
one to help you with the dog?
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Do you have other dogs inside your home?_______________ Names ____________________________
M/F ____ Age _______ Breed ____________________________________

Please describe your expectations of the "perfect" Service Dog and how it could help your quality of life.
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Anything else you would like for us to consider in reference to you obtaining a Service Dog?
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________

Applicant Signature: ______________________________________________

Printed Name: __________________________________________________

Date: ________________________________

For Office Use Only:

Received:___________________________________
Approved:___________________________________
Processing Fee Received: ______________________
Meeting Date: ______ Where: ___________________
Home Visit Date: _____________________________
Follow up: __________________________________