Cover Six Canines Handler Application

Name *

First

Last

Email *

Phone #

Phone number where we can reach you

Address

Address Line 2

City

State

Zip Code

Are you a Veteran or active duty?

If you are a Veteran which branch?

Are or were you a First Responder?

If you are or were a First Responder which type?

Do you have or can you obtain proof of service such as DD214 or letter from agency?

Has a doctor diagnosed you with disability?

What are your disability(s)?

Has or will a doctor write a letter stating that you would benefit from a Service Dog?

Do you currently have a dog?

If you plan on using this dog, what is the age and breed?

If you don't have a dog what breeds would you prefer?

Would you prefer a puppy or and adult?

Who lives with you?

Do you work? Full or part time?

Have you previously trained with any other organization? If so who?

Thank You

Thank your for contacting Cover Six Canines, and thank you for your service. We will be in contact with you as soon as possible.

Name