Committed Canine, Inc.

Please provide the following contact information:

Please identify and describe yourself:

Do you have a disability?

Yes No

Do you currently employ a Service Dog to mitigate your disability?

Yes No

Have you ever used a Service Dog to mitigate your disability?

Yes No

Have you read the Pre-Application information at the Committed Canine Website?

Yes No

Have you read the information about Fully Trained Service Dogs at the website, including the cost of the service?

Yes No

Do you believe you are capable of handling a trained Service Dog, including the need for daily training maintenance?

Yes No

Do you currently have the funds to pay for the training of a fully trained Service Dog?

Yes No

Would you like to have a dog that you current own professionally trained as your Service Dog?

Yes No - If No, skip to question 14

What is your dog's breed?

What is your dog's age?

What is your dog's gender?

Male - intact
Male - neutered
Female - intact
Female - spayed

If you don't have a dog ready to be professionally trained, what breeds interest you as your SD?

Why do you think that breed/breeds would be a good SD for you?

I need a Service Dog to help me with:

Mobility (balance / walking)
Mobility (pulling wheelchair)
Retrieving objects
A psychiatric disability (PTSD, panic/anxiety)
Autism
Alert (Seizure/Medical Alert)
Hearing Disability
Emotional Support

Describe your disability:

Describe at least three tasks that you want a dog to learn to mitigate your disability:

Are you able to travel to Brownstown, IL to receive training on how to handle your Service Dog?

Yes No

Describe your level of self confidence when you must learn something new:

bad poor average fair good

Describe your level of self confidence once you understand a task and have had some practice:

bad poor average fair good

How would you rate your ability to impose your will on someone else (1= not at all, 5 = I always win)

1 2 3 4 5

Have you trained a dog before?

Never
A pet, over 5 years ago
A pet, in the past 5 years
A Service Dog that I used or still use

Will you take your Service Dog to a current job that you hold outside of your home?

Yes No

Have you discussed the idea of acquiring a Service Dog with any family or friends with whom you share a home?

No
Yes
Not Yet, but plan to do that
I do not live with other people

How will you manage your SD for exercise / potty breaks:

Let out in fenced yard
Let out in un-secured yard
Walk on leash
Let out in enclosed kennel

Please describe any other pets that you have in your home (species, breed, gender, age, etc..)

If you had a Service Dog in the past, how did you acquire the dog?

An established Service Dog organization
A private trainer (fully trained dog)
A private trainer helped me train my own dog
I trained my own dog without support
I have never had a SD before

Please use this box to add any further information you may want to offer:

Will you be able to provide a letter from your doctor stating that you have a recognized disability?

Yes No