Committed Canine, Inc.

Application for Dog Locator Service Service

 

  This is the application for a the Dog Locator Service from Committed Canine, Inc. 

There is a $200 fee required prior to the service initiation.  If, during your own, concurrent search, you identify a dog, you will not receive a refund. 

This service is only available to individuals who intend to enroll in the T.E.A.C.H. program or utilize our professional training services for a Fully Trained Service Dog.

 


  1. Please provide the following contact information:

    Name
    Occupation
    Street Address
    Address (cont.)
    City
    State/Province
    Zip/Postal Code
    Country
    Work Phone
    Home Phone
    Name of Assistant
    E-mail
    Repeat E-mail
  2. Please provide the following:

    Date of Birth
    Sex Male Female
    Height provide this is you plan to use a dog for mobility and require a mobility harness
    Weight provide this is you plan to use a dog for brace or mobility work where the dog will need to support your weight, at times
     
  3. Do you have a disability?

    YES
    NO

  4. Is this application for a minor child?

    YES
    NO

  5. If a minor child please provide the name of a parent / guardian:


  6. Are you a military veteran?

    YES
    NO

  7. Do you currently have a Service Dog?

    YES
    NO

  8. Have you used a Service Dog in the past?

    YES
    NO

  9. When do you want the dog to begin training?

    immediately upon identification
    1-3 months
    3-5 months
    over 6 months from now

  10. What gender of dog do you prefer as your Service Dog?

    Male
    Female
    Doesn't matter

  11. Do you want to find a younger puppy that you are willing to raise for a few months before training?

    YES, I want to raise a puppy for a while
    NO, I don't want to deal with the dog until it's trained
    I could do either for the right dog

  12. What breed(s) of dog have you contemplated, if at all, as your future Service Dog?


  13. Why have you considered those breeds?


  14. Describe the amount of grooming you can handle:

    A once-a-week brushing seems overwhelming
    I can brush a dog once a week
    I don't mind brushing a dog a few times a week
    I don't want a dog with long hair that might matt up
    I plan to use, and I can afford a groomer - coat type isn't an issue for the right dog
    I plan to use a groomer - but, I can't afford expensive grooming, so coat type should be easy to maintain
    I want a dog with a non-shed coat and I know it will require a lot of grooming, and I can handle that
    just get me the best dog, I will be able to handle what ever coat type it has

  15. Have you read the information on the website about the Dog Locator Service:

    YES
    NO

  16. Have you read the pre-application information at the website?

    YES
    NO

  17. What service do you plan to use to have this dog trained as your Service Dog?

    T.E.A.C.H. train your own dog
    Fully Trained SD training
    I don't know yet
    I don't plan to use a Committed Canine service

  18. What is your top dollar limit that you can spend to acquire a dog to train as your Service Dog?

     This number should include any veterinary care it will need (like neutering) and any transportation costs:


  19. Do you currently have that total amount of money to spend on a dog, if it were to be identified soon?

    YES
    NO

  20. What sort of tasks do you need a Service Dog to perform to mitigate your disability?

    Mobility (Balance / walking)
    Mobility (pulling / wheelchair)
    Mobility (opening doors, turning off lights etc...)
    Retrieving objects
    A psychiatric disability (PTSD, panic/anxiety)
    An autism spectrum disorder
    Medical Response (to seizures, shifts from normal)
    Emotional Support
    Other

  21. If you chose Other, please describe:


  22. What is the distance you are currently willing to travel to acquire the dog?

    I cannot travel at all
    50 miles
    100 miles
    150 miles
    200 miles
    300 miles

  23. Are you able to travel to Brownstown, IL to receive training on how to handle your new dog?

    YES
    NO

  24. Describe your ability to impose your will upon someone / something (1= not at all, 5 = no problem)

    1 - not at all, that is really hard for me, I can't have a dog that might challenge my authority
    2
    3
    4
    5 - I'm used to taking control of myself and others all the time, I can handle a dog that might challenge me a bit

  25. Describe any other pets you have in your house (species, gender, age, spay/neuter):


  26. Please add any additional information you want us to know about what sort of dog you hope we locate as your future Service Dog


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

    YES
    NO


Copyright 2012 Committed Canine, Inc. All rights reserved.
Revised: 12/16/12