Veteran Application - Short Date MM slash DD slash YYYY Full Legal Name(Required) First Last Preferred NamePreferred PronounsDo you live within 90 minutes of the facility you are applying to train at?(Required)YesNOIf you answer no to this question, please stop filling out this form and call our Veteran Program Manager (603) 316 0952Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneDate of Birth(Required) MM slash DD slash YYYY Cell Phone(Required)Email(Required)Branch of Service Army Navy Marine Corps Air Force Coast Guard National Guard Reserves How did you hear about Operation Delta Dog?Have you received a diagnosis (diagnoses) of:(Required) PTSD TBI MST Are you currently seeing a behavioral health specialist (e.g, therapist)?(Required)YesNoAre you willing to start seeing a behavioral health specialist before starting the program?(Required)YesNon/aDo you have any physical limitations from past injuries or require assistive equipment (e.g., wheelchair, walker, cane, or prosthetics)?(Required)YesNoDo you currently have a personal care assistant (PCA) or require full-time assistance from a family member?YesNoAre you allergic to dogs?YesNoThird ChoiceAre any members of your household allergic to dogs?YesNoThird ChoiceList the names, relationship, and ages of everyone living in your home (other than yourself), or others that may frequent your residence on a regular basis.Please list other pets residing within the home (type, age, spayed/neutered, friendly with dogs, current with vaccinations, etc.)I understand that no dog is hypoallergenic. No person in my home, including myself, has an allergy to dogs. I understand that a dog allergy would preclude me from participating in this program(Required) Please check this box Type of residence(Required) Single Family Condo Multi-Family Apartment Shared Housing (e.g Sober House) Assisted Living Have you ever had to surrender a pet?(Required) Yes No **Routine dog care expenses can exceed $3,000 in a typical year (dog food, veterinary check-ups, medications, etc.) Costs may vary due to unexpected expenses (e.g. emergency care) throughout a dogs lifetime** Is this something that you would be able to cover? Yes No Do you have access to a reliable mode of transport? Yes No Have you ever been convicted of a felony or misdemeanor? Yes No Signature(Required)This acknowledges submission of this application Δ Share this content: