Veteran Application General InformationDate MM slash DD slash YYYY Full Legal Name First Last Preferred Name Preferred Pronouns Address 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 Date of Birth SSN Home PhoneCell PhoneEmail Branch of Service Army Navy Marine Corps Air Force Coast Guard National Guard Reserves Please tell us about your military experiencePlease upload a copy of your DD214 Drop files here or Select files Max. file size: 2 GB. How did you hear about Operation Delta Dog? MEDICAL HISTORY/INFORMATIONHave you received a diagnosis (diagnoses) of: PTSD TBI MST Select AllDo you currently have a healthcare provider (e.g., primary care physician)? Yes No Are you currently seeing a behavioral health specialist (e.g., therapist)? Yes No Have you discussed this application with your provider? Yes No Are you allergic to dogs? Yes No Do you have any physical limitations from past injuries or require assistive equipment (e.g., wheelchair, walker, cane, or prosthetics)? Yes No If ‘yes’, please describe:Do you currently have a personal care assistant (PCA) or require full-time assistance from a family member? Yes No Are you currently on any medications? Yes No If ‘yes’, how many medications do you take on a daily basis? 0-3 4-7 8 or more Select all reasons and severity level (1 – Least Severe to 5 – Most Severe) for requesting a service dog:Reduce feelings of isolation/loneliness/hopelessness.12345N/AReduce irritability and/or feelings of anger.12345N/AIncrease feelings of security/safety at home.12345N/AIncrease feelings of security/safety in public.12345N/AReduce symptoms of anxiety.12345N/AReduce symptoms of depression.12345N/AWaking/Assistance during nightmares.12345N/AAssistance during emergencies.12345N/AAssistance picking up/retrieving items.12345N/AProviding bracing/support to sit, stand, walk, or balance12345N/AOther (please describe below).12345N/APlease describe hereEMERGENCY CONTACT INFORMATIONIn the event of emergency, please contact:Name First Last PhoneEmail Relationship RESIDENTIAL/HOUSEHOLD INFORMATIONLiving environment: City Suburb Rural Please describe your neighborhoodType of residence: Single Family Condo Multi-Family Apartment Shared Housing (e.g Sober House) Assisted Living Is your home a: Single Level Multi-Level Do you Own Rent If you rent your home, has your landlord/management company been informed about your interest in obtaining a service dog? Yes No Landlord/Management Details: Name First Last PhoneEmail Address 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 Does your property include a fenced-in area? Yes No List 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.NameRelationshipAge(F/T - P/T) Add RemoveAre all members of your household aware of and in agreement with the addition of a service dog in the home? Yes No Printed Name of Additional Resident Signature of Additional Resident Are any members of your household allergic to dogs? Yes No Is anyone in the household nervous/unsure around dogs? Yes No Do you or does anyone in your residence currently own a dog? Yes No Please list other pets residing within the home Please list other pets residing within the home (type, age, spayed/neutered, friendly with dogs, current with vaccinations, etc.)Current Veterinarian: First PhoneWORK / SCHOOL / ACTIVITIESAre you currently employed? Yes No If so, on what basis? Full Time Part Time Seasonal Per Diem Place of Employment Are you a retiree? Yes No Are you currently enrolled in school? Yes No If yes, on what basis? Full Time Part Time School Name: Have you discussed the possibility of having a service dog with your place of employment or school? Yes No If applicable, do you plan on bringing your dog to work/school? Yes No If no, why not? If you do not currently fit any of the aforementioned options, please describe your situation below i.e. volunteer, SSI, SSDIDo you have any hobbies or interests? If so, please describe: Do you have any major life events at the present time or in the near future: e.g. job change, marriage, birth, etc. ? DOG EXPERIENCE / CONSIDERATIONSHave you previously owned a dog? Yes No Other than your current pet Please describe the situation Have you ever had to surrender a pet? Yes No Please describe the situation Have you had any previous experience working in dog obedience classes and/or workshops: Yes No Do you have any experience handling dogs if you've never owned a dog previously? Yes No If so, please describe: Do you have someone that would be able to assist you with your service dog should you become ill or need help? Yes No If yes, please describe Do you travel frequently Yes No If yes, how often? Would/Will you have the opportunity to bring your service dog with you on trips? Yes No Would your service dog accompany you to social events? 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 TRAININGWill you be able to arrange your schedule to attend training sessions with your service dog at Operation Delta Dog's training facility on a weekly basis? Yes No What time of day are you available for classes (check all that apply)? Morning Afternoon Evenings Do you have access to a reliable mode of transport? i.e. car, bus, public transportation, etc.? Do you have any concerns about receiving a service dog and participating in the training program? Yes No If so, please describe Are you interested in being matched with a mentor; a veteran graduate who will be available for support throughout your training? Yes No Date upon which you are available to begin training with Operation Delta Dog: Month Day Year BACKGROUND CHECKHave you been convicted of a felony or misdemeanor? Yes No If so, please describe Have you resided in any states besides your current location in the past 10 years? Yes No If yes, please list: I consent to Operation Delta Dog accessing my criminal background check for all applicable states noted above: I agreeNOTE: Applicants must notify Operation Delta Dog immediately if they are arrested or convicted of a felony or misdemeanor during the training process. A conviction or arrest will not necessarily disqualify applicants or participants. Δ Share this content: