Application

Need a Battle Buddy?

Have you been diagnosed with Post Traumatic Stress*
Have you ever been diagnosed with Traumatic Brain Injury
Are you a Survivor of Sexual of Military Sexual Injury/Trauma
Name of the Medical Center/Physician that determined the diagnosis
Address of Center/Physician
Harming Yourself?
If yes, explain
Harming an animal
If yes, explain
Violent with others
If yes, explain
Please provide 3 personal references and their phone numbers. One of which may not be a relative or someone living with you.
Phone
Phone
Phone
Military Service Information
Branch of Service
Entered Active Service Date
Date Format: MM slash DD slash YYYY
Discharge Date
Date Format: MM slash DD slash YYYY
Entered Active Service MOS
Discharge MOS
I hereby agree to the following statement:
V.E.T. Service Dogs NFP has authority and permission to contact any person you have referenced on this form.
Signature*
Date
Date Format: MM slash DD slash YYYY
Please submit a copy of a signed letter from a doctor, psychiatrist, psychologist or therapist that has diagnosed your condition of PTSI, TBI, MSI. You can also supply a rating from V.A Please scan and submit a copy of your D.D. 214, and please block out social security number
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If you would like any assistance, please call us directly at (708) 274-7678