Name

Email Address

Contact Number

What city/town do you currently live in?

What is your age?

Are you applying as a veteran or first responder? Are you applying as a veteran or first responder? Veteran First Responder

In what capacity do you serve as a first responder?

Can you provide us with a copy of your NYSDOH certificate? Can you provide us with a copy of your NYSDOH certificate? Yes No

How many years have you held this position?

What Branch of Service were you in?

How many years did you serve?

Can you provide us with a DD214? Can you provide us with a DD214? Yes No

Are you currently receiving any VA benefits? Are you currently receiving any VA benefits? Yes No

Please provide the name of someone, other than a person that you live with, who will be able to care for your dog temporarily if needed.

Emergency contact phone number:

How many people currently live in your household?

Do you own your home or rent? Do you own your home or rent? Own Rent

Can you provide proof of home ownership? Can you provide proof of home ownership? Yes No

Can you provide you landlords name and contact information? Can you provide you landlords name and contact information? Yes No

Landlords name and contact:

Do you have a fenced in yard? (This is not a requirement, it helps us determine the best dog for your lifestyle.) Do you have a fenced in yard? (This is not a requirement, it helps us determine the best dog for your lifestyle.) Yes No

Do you have any health issues that you would like to have a confidential conversation with our application evaluators about? (Health concerns will not prevent you from getting a dog from us, however we need to be aware of any issues that might be a factor in helping us choose the proper dog for you.)

Can you provide a letter from a health care provider stating you require or would benefit from a service animal? Can you provide a letter from a health care provider stating you require or would benefit from a service animal? Yes No

Have you ever considered hurting yourself or others? Have you ever considered hurting yourself or others? Yes No

Are you currently in any form of counseling? Are you currently in any form of counseling? Yes No

How often and where do you attend?

What is the approximate date you started counseling?

Have you received any drug or alcohol treatment in the past 12 months? Have you received any drug or alcohol treatment in the past 12 months? Yes No

Are you currently following an aftercare recovery plan? Are you currently following an aftercare recovery plan? Yes No

Have you ever been convicted of a misdemeanor or a felony? Have you ever been convicted of a misdemeanor or a felony? Yes No

Please describe.

Has any court ever issued an order of protection against you? Has any court ever issued an order of protection against you? Yes No

Please list the year, the court, and the offense.

Are you currently employed? Are you currently employed? Yes No

How many hours per week do you work?

Will you require your PTS or light mobility service dog to accompany you to work? Will you require your PTS or light mobility service dog to accompany you to work? Yes No

How social are you?

How often do you exercise?

Do you have any other animals in the house? Do you have any other animals in the house? Yes No

How many and what kind of animals do you have?

Are they current on their vaccinations? Are they current on their vaccinations? Yes No

What size dog are you looking for?

Would you like us to temperament test your own dog? Would you like us to temperament test your own dog? Yes No

Are you willing to commit to attending 8-12 months of dog training classes (one class per week)? Are you willing to commit to attending 8-12 months of dog training classes (one class per week)? Yes No

What are five tasks you need your service dog to do for you?

Do you believe your current situation will allow you to keep a service dog for at least 8-10 years? Do you believe your current situation will allow you to keep a service dog for at least 8-10 years? Yes No

Will your service dog spend most of its time with you both at home and outside of the home (and not confined alone/by itself). Will your service dog spend most of its time with you both at home and outside of the home (and not confined alone/by itself). Yes No

Do you understand that a service dog is not a family pet and has been trained for specific jobs to perform for you and should therefore interact mainly with you? Do you understand that a service dog is not a family pet and has been trained for specific jobs to perform for you and should therefore interact mainly with you? Yes No

Do you acknowledge that by taking one of our service dogs, you are a representative for Operation At Ease and the service dog industry and will be expected to maintain both your dogs training skills and your skills as an owner/handler? Do you acknowledge that by taking one of our service dogs, you are a representative for Operation At Ease and the service dog industry and will be expected to maintain both your dogs training skills and your skills as an owner/handler? Yes No

Do you agree that your service dog will not be off its leash except in a secure area? Do you agree that your service dog will not be off its leash except in a secure area? Yes No

Do you agree that you will take full responsibility for the care of your service dog as far as their safety, health & welfare? And if you are not able to take full responsibility for these things, a qualified person will do it for you? Do you agree that you will take full responsibility for the care of your service dog as far as their safety, health & welfare? And if you are not able to take full responsibility for these things, a qualified person will do it for you? Yes No

Will you or a qualified person feed your service dog a good quality dog food twice a day and maintain its ideal weight? Will you or a qualified person feed your service dog a good quality dog food twice a day and maintain its ideal weight? Yes No

Will you or a qualified person ensure your service dog gets daily exercise? Will you or a qualified person ensure your service dog gets daily exercise? Yes No

Will you or a qualified person take full responsibility for cleaning up after your dog in public places? Will you or a qualified person take full responsibility for cleaning up after your dog in public places? Yes No

Do we have your permission to contact anyone who is listed on this application if we need further information? Do we have your permission to contact anyone who is listed on this application if we need further information? Yes No

When are you available to attend classes?

The Operation At Ease training center is located in Rotterdam, NY. Upon successful completion of classroom training we begin Public Access training, which is done at various locations in the Capital District. Do you have reliable transportation to get you and your service dog in training to and from all training and public access classes for a eight month period? The Operation At Ease training center is located in Rotterdam, NY. Upon successful completion of classroom training we begin Public Access training, which is done at various locations in the Capital District. Do you have reliable transportation to get you and your service dog in training to and from all training and public access classes for a eight month period? Yes No

List three personal references we can contact (Name, Relationship, Phone Number).

Please provide us with a name and number of someone who can take care of your dog in your absence. (or in the event of an emergency)

I understand that if I do not complete this program in its entirety my dog will not be designated as an Operation At Ease inc trained service dog. The dog will remain in my care as a pet only after an Operation At Ease representative has determined my situation is safe for myself and the dog. If they deem my situation unsafe the dog will be removed from my home I understand that if I do not complete this program in its entirety my dog will not be designated as an Operation At Ease inc trained service dog. The dog will remain in my care as a pet only after an Operation At Ease representative has determined my situation is safe for myself and the dog. If they deem my situation unsafe the dog will be removed from my home Yes, I understand No, I do not understand

Name

Email Address

Contact Number

What city/town do you currently live in?

What is your age?

Are you applying as a veteran or first responder? Are you applying as a veteran or first responder? Veteran First Responder

In what capacity do you serve as a first responder?

Can you provide us with a copy of your NYSDOH certificate? Can you provide us with a copy of your NYSDOH certificate? Yes No

How many years have you held this position?

What Branch of Service were you in?

How many years did you serve?

Can you provide us with a DD214? Can you provide us with a DD214? Yes No

Are you currently receiving any VA benefits? Are you currently receiving any VA benefits? Yes No

Please provide the name of someone, other than a person that you live with, who will be able to care for your dog temporarily if needed.

Emergency contact phone number:

How many people currently live in your household?

Do you own your home or rent? Do you own your home or rent? Own Rent

Can you provide proof of home ownership? Can you provide proof of home ownership? Yes No

Can you provide you landlords name and contact information? Can you provide you landlords name and contact information? Yes No

Landlords name and contact:

Do you have a fenced in yard? (This is not a requirement, it helps us determine the best dog for your lifestyle.) Do you have a fenced in yard? (This is not a requirement, it helps us determine the best dog for your lifestyle.) Yes No

Do you have any health issues that you would like to have a confidential conversation with our application evaluators about? (Health concerns will not prevent you from getting a dog from us, however we need to be aware of any issues that might be a factor in helping us choose the proper dog for you.)

Can you provide a letter from a health care provider stating you require or would benefit from a service animal? Can you provide a letter from a health care provider stating you require or would benefit from a service animal? Yes No

Have you ever considered hurting yourself or others? Have you ever considered hurting yourself or others? Yes No

Are you currently in any form of counseling? Are you currently in any form of counseling? Yes No

How often and where do you attend?

What is the approximate date you started counseling?

Have you received any drug or alcohol treatment in the past 12 months? Have you received any drug or alcohol treatment in the past 12 months? Yes No

Are you currently following an aftercare recovery plan? Are you currently following an aftercare recovery plan? Yes No

Have you ever been convicted of a misdemeanor or a felony? Have you ever been convicted of a misdemeanor or a felony? Yes No

Please describe.

Has any court ever issued an order of protection against you? Has any court ever issued an order of protection against you? Yes No

Please list the year, the court, and the offense.

Are you currently employed? Are you currently employed? Yes No

How many hours per week do you work?

Will you require your PTS or light mobility service dog to accompany you to work? Will you require your PTS or light mobility service dog to accompany you to work? Yes No

How social are you?

How often do you exercise?

Do you have any other animals in the house? Do you have any other animals in the house? Yes No

How many and what kind of animals do you have?

Are they current on their vaccinations? Are they current on their vaccinations? Yes No

What size dog are you looking for?

Would you like us to temperament test your own dog? Would you like us to temperament test your own dog? Yes No

Are you willing to commit to attending 8-12 months of dog training classes (one class per week)? Are you willing to commit to attending 8-12 months of dog training classes (one class per week)? Yes No

What are five tasks you need your service dog to do for you?

Do you believe your current situation will allow you to keep a service dog for at least 8-10 years? Do you believe your current situation will allow you to keep a service dog for at least 8-10 years? Yes No

Will your service dog spend most of its time with you both at home and outside of the home (and not confined alone/by itself). Will your service dog spend most of its time with you both at home and outside of the home (and not confined alone/by itself). Yes No

Do you understand that a service dog is not a family pet and has been trained for specific jobs to perform for you and should therefore interact mainly with you? Do you understand that a service dog is not a family pet and has been trained for specific jobs to perform for you and should therefore interact mainly with you? Yes No

Do you acknowledge that by taking one of our service dogs, you are a representative for Operation At Ease and the service dog industry and will be expected to maintain both your dogs training skills and your skills as an owner/handler? Do you acknowledge that by taking one of our service dogs, you are a representative for Operation At Ease and the service dog industry and will be expected to maintain both your dogs training skills and your skills as an owner/handler? Yes No

Do you agree that your service dog will not be off its leash except in a secure area? Do you agree that your service dog will not be off its leash except in a secure area? Yes No

Do you agree that you will take full responsibility for the care of your service dog as far as their safety, health & welfare? And if you are not able to take full responsibility for these things, a qualified person will do it for you? Do you agree that you will take full responsibility for the care of your service dog as far as their safety, health & welfare? And if you are not able to take full responsibility for these things, a qualified person will do it for you? Yes No

Will you or a qualified person feed your service dog a good quality dog food twice a day and maintain its ideal weight? Will you or a qualified person feed your service dog a good quality dog food twice a day and maintain its ideal weight? Yes No

Will you or a qualified person ensure your service dog gets daily exercise? Will you or a qualified person ensure your service dog gets daily exercise? Yes No

Will you or a qualified person take full responsibility for cleaning up after your dog in public places? Will you or a qualified person take full responsibility for cleaning up after your dog in public places? Yes No

Do we have your permission to contact anyone who is listed on this application if we need further information? Do we have your permission to contact anyone who is listed on this application if we need further information? Yes No

When are you available to attend classes?

The Operation At Ease training center is located in Rotterdam, NY. Upon successful completion of classroom training we begin Public Access training, which is done at various locations in the Capital District. Do you have reliable transportation to get you and your service dog in training to and from all training and public access classes for a eight month period? The Operation At Ease training center is located in Rotterdam, NY. Upon successful completion of classroom training we begin Public Access training, which is done at various locations in the Capital District. Do you have reliable transportation to get you and your service dog in training to and from all training and public access classes for a eight month period? Yes No

List three personal references we can contact (Name, Relationship, Phone Number).

Please provide us with a name and number of someone who can take care of your dog in your absence. (or in the event of an emergency)

I understand that if I do not complete this program in its entirety my dog will not be designated as an Operation At Ease inc trained service dog. The dog will remain in my care as a pet only after an Operation At Ease representative has determined my situation is safe for myself and the dog. If they deem my situation unsafe the dog will be removed from my home I understand that if I do not complete this program in its entirety my dog will not be designated as an Operation At Ease inc trained service dog. The dog will remain in my care as a pet only after an Operation At Ease representative has determined my situation is safe for myself and the dog. If they deem my situation unsafe the dog will be removed from my home Yes, I understand No, I do not understand