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certified team online application

SECTION #1
Last Name:

 First Name:
 Today's Date:
Mailing Address:
City:
 State:
 Zip Code:
U.S. Citizen?
Yes No		 County of Residence:
Home Phone:
 Mobile Phone (optional):
Email Address:
Name of Dog:
 Breed:
 Color:
D.O.B of Dog:
 Tattoo or Microchip # (optional):
County of License:
 Tag #:

Year:
Name of Veterinarian:
 Veternarian's Phone:
How long have you and your dog trained together? Years Months
     
Please indicate which type(s) of work your dog has been trained to perform (please check all that apply):
Hearing Assist
Medical Alert
Mobility Assistance
Psychological Assistance

SECTION #2
Information for Certification Materials
As a part of the certification materials the FSDS issues you an emergency contact information card, to be carried in the pocket of the vest. In the event that you are ill or injured and a temporary separation of you and your dog must occur, it is imperative that you specify a designated caregiver for your service dog.
Primary designated caregiver:
Phone:
 Alt. Phone #1 (optional):
 Alt. Phone #2 (optional):
Secondary designated caregiver:
Phone:
 Alt. Phone #1 (optional):
 Alt. Phone #2 (optional):

SECTION #3
Size of Vest    

Vest sizes are determined based on the weight of your dog. Please indicate the vest size you will require upon successful completion of the SD Certification Test:

SECTION #4
Documents to be submitted along with mailed applications:
A recent photo of your and your dog together. This must be a recent photo of you and your dog with your faces as close together as possible. Separate photos of each of you are not acceptable.
Photo must be in .jpg format
A copy of your CGC Certificate, dated NO SOONER THAN your dogs first birthday.
CGC Certificate must be in .pdf format.
Veterinary Statement, signed by your veterinarian within 30 days of this application.
Veterinary Statement must be in .pdf format.
Statement of Disability, signed by your treating physician within 30 days of this application.
Statement of Disability must be in .pdf format.

SECTION #5
Acknowledgement and Acceptance of Guidelines

I understand that the Foundation for Service Dog Support, Inc. (FSDS) reserves the right to revoke the CSD Team status for any SD team who fails to comply with the published guidelines. I understand that if a complaint is lodged against my team, the FSDS will investigate fully and I will be given the opportunity to respond to the complaint. The FSDS may elect to either dismiss the complaint fully, or revoke my CSD Team status, depending on the nature of the complaint. I understand that the decision of the FSDS will be final and that the initial application processing fee as well as any other testing and certification fees will be non-refundable. In addition, I understand that if the certification of my team is revoked for any reason, I will be obligated to return the vest to the FSDS.

I acknowledge that I have read and understand the CSD Team Manual. I understand the material and agree to abide by all the guidelines that are established by the FSDS.

A non-refundable application processing fee of $10 is required Once you click on the submit button below, you will be taken to the payment page.

 

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