Sample Application
PART THREE: LIVING SITUATION INFORMATION
Describe your living quarters:
Do you and/or your family own your own
home, or rent?
Is the area in which you live:
Urban:
Suburban:
Rural:
Do you live in a:
House:
Apartment:
Condominium:
Do you have your own room?
Is your home wheelchair accessible?
Are you able to leave your house without assistance?
Do you have a fenced-in yard?
Where will you take the dog for elimination needs?
How will you clean up waste from your dog?
Are you prepared to go outside to take the dog for elimination needs and exercise when
the weather is rainy, snowy, or cold? How will you do this?
Do you have a park,
or other area nearby where you can take the dog for exercise? Where is this in relation to your living quarters? How will
you get there?
Are you able to use public transportation from your house unassisted?
Will other people who are in your life (family, spouse, children, roomates, attendants), be
supportive of you having a service dog?
Who is in your life that would be affected? List the people you can think of who will be affected
if you get a service dog.
Have you talked to each one of them about your desire to get a service dog?
What were the responses of each of these people about you wanting to get a service dog?
List these people and write down their responses.
Please list all those that live with you:
Name:
Relationship to You:
Age:
Name:
Relationship to You:
Age:
Name:
Relationship to You:
Age:
Does anyone living with you have any disabilities?
If Yes, please describe:
List and Describe any animals now living with you: