Applicant Information
Are you a Veteran of the U.S. Military?
Yes No
If yes, are you active duty?
Yes No
*Name: First, Middle, Last
Date of Birth
Street Address
City
State
Zip
All U.S. citizens who reside outside the U.S. must possess a current passport to travel to and from the U.S. per International Law.
Mailing Address, if different from above
Home phone
Work phone
Cell phone
*E-mail address
How long have you resided at you current address?
Are you contemplating a move in the near future?
Yes No
If yes, please explain.
With whom do you reside? (Self, spouse, parents, children, etc.)
Number of children under the age of 18 in your household:
Have you previously had a guide dog?
Yes No
If yes, please list dates of service:
From which organization(s) did you receive your previous guide(s)?
Please click the Submit button to proceed to Part Two of this application.
Please click the submit button just once. The application may take a minute to process.
*Required field.