Veteran Application

Thank you for your interest in obtaining a service dog. Please fill out our online application (on the right side of this page). We will review all applications. However, because of the volume of applications we receive, it can take 5-10 business days before we respond. If we need more information we will contact you. Please do not submit more than one application.

*required field

Veteran Application

First Name *

Middle Name

Last Name *

Address 1 *

Address 2

City *

State *

Zip *

County

Phone *

Email *

Branch of Service *

Rank *

Military Occupational Skill *

Years Served *

Type of Discharge *

Did you serve in combat? *

Yes
No

If yes, where?

Have you been awarded the purple heart? *

Yes
No

If yes, date received:

Have you received a VA rating? *

Yes
No

If yes, what is your VA rating?

Please list your VA Case Manager Full Name, Phone Number, and E-mail:

Please list your Primary Care Doctor Full Name, Phone Number, and Facility:

Have you received a DoD rating? *

Yes
No

If yes, what is your DoD rating?

What injuries or conditions are service connected? *

Are you required to use a wheelchair?

Yes
No

Are you required to use a prosthetic?

Yes
No

Are you required to use any assistance to walk?

Yes
No

If yes, what device is required?

Do you have a caregiver?

Yes
No

If yes, what is the relation and their contact information?

Do you have an eBenefits account?

Yes
No

Do you have a myhealthevet account?

Yes
No

What type of healthcare do you have?

Are you currently employed? If yes, with who?

Are you currently in school? If yes, where?

Have you applied for a service dog before?

Yes
No

If yes, with what organization?