PILOT DOGS, INC
PILOT DOGS, INC
625 West Town Street-Columbus, OH 43215
Phone: 614/221-6367 Fax: 614/221-1577
APPLICATION FOR A PILOT DOG
Date_______________________________
Name(Mr./Mrs./Ms.)_________________________________________________
(First) (Middle) (Last)
Address_______________________________________________________________
City, State, Zip________________________________________________________
E-mail:
Telephone:(Home)________________________(Cell)_______________________
Date of Birth__________Height_________Weight________Married____
Single_________Medical Insurance Company___________________________
Type of Home: Apartment _____ City Home ______ Country Home ______
Are you a Veteran? __________
Name of Persons in your home: Age Relationship to You
In case of Emergency, contact:______________________Number___________
Education: Elementary__________High School_________College__________
Orientation & Mobility Training?____________Agency________________
Are you employed?_____By Whom________________Duties_______________
Future Plans__________________________________________________________
Do you have experience in use of a guide dog?_________________________
Guide Dog School(s) Attended______________________Date Attended_____
Number & Types of pets in the home__________________________________
Do you travel alone?____________________With a cane?__________________
A non-profit organization to train and furnish Pilot Dogs to guide the Blind
Other Side
Give Cause and date of Blindness?____________________________________
Degree of vision: Total_______Light Perception___________Partial________
Describe any physical limitations other than blindness_________________
REFERENCES: * Please print or type neatly * Provide Full Address or E-mail
List (4) Friends, clergy, co-workers, neighbors, (not Relatives), O & M Instructors or Counselors.
1) ________________________________Street____________________________
Email: City, State, Zip________________________
2) ________________________________Street____________________________
Email City, State, Zip________________________
3) ________________________________Street____________________________
Email City, State, Zip________________________
4) ________________________________Street____________________________
Email City, State, Zip________________________
Name of nearest airport? ___________________________________________
If you live within 200 miles, which means of transportation you would you prefer:
Bus_________________Train__________________Auto_____________
My preference for breed of dog ______________________________________
IN ALL CASES, THE TRAINER MAKES THE FINAL SELECTION OF
DOG TO MATCH THE WORKING ABILITIES AND NEEDS OF THE
STUDENT.
How did you hear about Pilot Dogs?
Do you agree not to use the Pilot Dog for mendicancy? _________( We
consider mendicancy the acceptance of money without rendering comparable service or merchandise.)
................
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