K9 Line Service Dog Application Please Complete All Areas of the Application Step 1 of 2 50% Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY HeightWeightAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Email* Enter Email Confirm Email Do You Work?*YesNoIs Your Employer Aware Your Service Dog Will Be With You At Work?YesNoAre You a Veteran of any War or the US Armed Services or a Former Overseas Contractor*YesNoHave you been diagnosed with a disability by the VA or by a DBA assigned physician?*YesNoCan you provide a copy of your DD214 or if a contractor can you provide a letter of verification of employment or a copy of your defense base compensation(DBA) LS202 claim form?*YesNoBefore you progress in the application process it is very important that you understand owning a service dog requires a great deal of responsibility and continued commitment to training. A service dog must be with his or her handler 24 hours a day and 7 days a week. This can be a inconvenient and difficult when planning vacations, nights out with friends or family, and sporting events or concerts. However, you will never have a more loving and loyal friend. Do you feel as though you are ready for a service dog?*YesNo If you answered yes to the last 4 questions in section A: first and foremost, THANK YOU FOR YOUR SERVICE. Secondly, congratulations we are both happy you came to us and honored to say you are qualified to receive a K9line service dog and free training. The next questions are designed for our selection of your service animal to meet your specific needs. Please know that there are no wrong answers because we vow to never refuse a veteran based on his or her disability. In addition, your answers are protected under the Health Insurance Portability and Accountability Act (HIPPA). This information is for the canine selector onlyPlease take a moment to tell us about your disability, how you were injured, where the injury occurred, what you are looking for a service dog to help you with, and any physical or psychological limitations or symptoms you may have.Do You Currently Own Any Pets?*YesNoDo You Have Any Allergies?*YesNoHave You Ever Owned a Dog?*YesNoHave You Had Any Formal Dog Training?*YesNoDo You Live in a Home or Apartment?*Is Your Yard Fenced In?*YesNoDo You Have Children? If so what are their ages.* This iframe contains the logic required to handle Ajax powered Gravity Forms.