Last Name: _____________________ First Name: ____________________ M.I. ______
Cell Phone #: ___________________________Home #: ______________________________
Email Address: _____________________________________________________________
Address (Street, Apt #):__________________________________________________
City / State / Zip: ______________________________________________________________
Branch:
ARMY
Status:
ACTIVE
NAVY
AIR FORCE
RETIRED
Years of Service:
MARINE CORPS
COAST GUARD
GUARD/RESERVES
Honorable Discharge: Yes / No
Conflicts Served In: ____________________________________________________________
Medical Diagnosis / Syndrome:
Please provide a brief background of yourself before, during and post military career:
Please attach DD-214 and/or Military ID Here:
Last Name, First Name
Interview Worksheet
__________________________
Application Date
1. How did you hear about our organization? Other (Explain)
2. Tell us your about yourself, your service, your family, etc....
3.What type of companion are you looking for: Service Dog (PTSD)
4. What can Companions for Heroes do for you? How will this adoption help?
a. What kind of behavioral issue are you concerned about? (Barking, Jumping, etc..)
5.Have you discussed getting a companion animal with the rest of the household, and
does everyone support the adoption? In addition to yourself, who else will participate
in the care of the animal?
a. How many animals have you had in the past and where are they now?
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b. Have you ever rehomed or given up a dog to a shelter? Why? No
6. Do you rent or own your home? Live with Family
a.What is the policy for pets on the property and may we contact renting
agency/property management? Allowed - Deposit
Name
Street Address
City
State
Zip
Tel#
a.Can you afford the deposit required? No
7. What are your thoughts about what type of animal you are looking for?
Size: Any!
Breed:
Age: Any
Gender: Either
8. What will be the living conditions for the animal?
a. How many hours per week do you work? How often will the dog be alone? What is your plan for when
he or she is alone?
b. Does anyone supporting you have allergies to pets?
c. Where is the closest dog park? Are you able to walk or play with the dog?
9. Do you currently have pets? If so, why are you looking to adopt an additional pet?
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10. Do you understand the financial responsibilities of owning a pet? Are you able
to afford the extra expenses to your budget (approximately $100 a month)? What
about a medical emergency that might run over $1000 like a broken leg, bloat, or
surgery to remove bladder stones?
11.What training methods are you familiar with?
a.Do you know how to crate train? No
12. With rescue animals there is a settling in period that takes place.
Are prepared for this issue if it arises? No
13. What other questions do you have for me?
14.Will you be selecting your own companion or looking for adoption assistance?
I have a recently adopted shelter dog I would like to train
15. As Companions for Heroes is a Non-Profit organization, we rely heavily on
donations. C4H has partners that assist us in receiving donations- would you be
willing to speak with media or partners of the organization to help us continue
our efforts? If you are not willing to speak, would you be willing to provide written
testimonial and photos we may use on your behalf?
No, Please respect my privacy
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