Veterans Moving Forward, Inc.
909 N. Washington St. Suite 410, Alexandria, VA 22314
1-866-375-1209  www.vetsfwd.org
Service Dog Application
Dear Veteran,
We’re glad you found us. As you probably know, Veterans Moving Forward (VMF) trains and
provides service dogs to veterans with physical and mental health challenges at no cost to the
veteran. We pride ourselves on a high success rate placing service dogs with veterans. It is a
result of our comprehensive matching process, and that starts with this application. Please note
that submitting an application does not guarantee receipt of a service dog.
The application and placement process can take several months. To help the process move
smoothly and quickly, please ensure to submit a complete application to VMF including all
required documentation and attachments (listed at the top of the application). Once received,
VMF will contact you and your health care team to ensure your application package is complete,
to address any of your questions, and determine if a service dog is appropriate for you. This
dialogue will take place over the phone, as well as at in-person interviews. You need to ensure
that you have a signed release on file with your health care team so that they will take VMF’s
phone calls, confirm you are a patient, and discuss your condition(s) with our doctors, nurses
and social workers. You must also be able to travel from your hometown to VMF Headquarters
in northern Virginia at least twice, sometimes three times.
You can find more detailed information about each step of the application process, as well as
sample interview questions, by visiting our website www.vetsfwd.org, clicking “What We Do”
and then “Veteran Information.”
We look forward to learning more about you. Thank you for your service to our country. We
hope to be of service to you.
Sincerely,
LT Mike Turner, USN Retired
Veteran Coordinator
Page 1
VMF, Inc., Proprietary
As of Jan. 5, 2012
Veterans Moving Forward, Inc. is a 501(c)(3) public charity that provides service dogs
to veterans with physical and mental health challenges.
Service Dog Application
Application
A completed application must include the following:
1.
The completed application form with signature.
2.
Medical History form completed by your physician, primary care specialist or caseworker.
Note: no special form is needed – provide in whatever format is used in your facility.
3.
A copy of your DD 214 and other official document(s) from the VA verifying your Summary of
Benefits or service-connected disability. If still on active duty, provide copy of PCS orders.
4.
A letter of reference from a therapist, social worker, counselor or other professional with
whom you have contact.
5.
A photo of yourself and brief autobiography highlighting:
 Your past animal connection
 Why having a service dog would benefit you
Date: __________________
Applicant’s Name: ____________________________ Nickname (if any): __________________
Branch of Service: _____________________________ Pay Grade/Rank: __________________
Address: ____________________________________________________________________
City: __________________ County: ___________ State: ___________ Zip: ______________
Is this a  Temporary Address or  Permanent Address
Preferred means of communication:  Phone
 E-mail
Daytime phone number:
_____________
 work  home  cell
Evening phone number:
_____________
 work  home  cell
Other (Please specify):
_____________
 work  home  cell
E-mail address (work): _________________ E-mail address (home): ___________________
Occupation: ____________________________ Spouse’s Occupation: ____________________
Date of Birth: ______________________ Gender:  Male  Female
Marital Status: Single Married Divorced Do you have children:  Yes  No If yes,
how many and what age(s)? _____________________________________________________
Emergency Contact Information
Name: ________________________________ Contact # _____________________________
What is your primary disability? ___________________________________________________
____________________________________________________________________________
____________________________________________________________________________
If you have been diagnosed with post-traumatic stress disorder (PTSD), how acute are your symptoms,
i.e., how often do you have flashbacks? How isolated are you? How angry do you get, and how often?
How well do you sleep? ________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Are you in the VA system?  Yes  No Is your disability progressive?  Yes  No
Additional Information: __________________________________________________________
Page 2
VMF, Inc., Proprietary
As of Jan. 5, 2013
Veterans Moving Forward, Inc. is a 501(c)(3) public charity that provides service dogs
to veterans with physical and mental health challenges.
Service Dog Application
Application
___________________________________________________________________________________
Case Manager: ___________________________
_________ May we contact?  Yes  No
Phone: _________________________________ E-mail: _____________________________
Physician: ______________________________________
May we contact?  Yes  No
Address: ____________________________________________________________________
City: __________________ County: ___________ State: ___________ Zip: ______________
Phone: _________________________________ E-mail: _____________________________
Therapist: ______________________________________
May we contact?  Yes  No
Phone: _________________________________ E-mail: _____________________________
Therapist: ______________________________________
May we contact?  Yes  No
Phone: _________________________________ E-mail: _____________________________
Approximate weight: _______________________ Height: _____________________________
What other medical problems do you have? _________________________________________
____________________________________________________________________________
How does this affect your daily living skills? _________________________________________
____________________________________________________________________________
____________________________________________________________________________
Please check all that apply:
 Deafness
 Speech Impairment
 Reduced Stamina
 Hearing Loss
 Coordination Problems
 Limited Mobility
 Memory Loss
 Spasticity
 Slowed Development
 Vision Impairment
 Muscular Weakness
 Other: _____________________________________________________________________
Do you have any of the following?
 Allergies
 Chronic pain
 Heightened emotions
 Depression
 Skin sensitivity
 Balance
 Brittle bones
 Sensitivity to heat/cold
 Seizures If yes, what type, how often, what treatments/medications are you (or have you)
using to control the seizures? ____________________________________________________
 Other: _____________________________________________________________________
Do you use any of the following?
 Prosthesis
 Leg brace
 Electric wheelchair
 Manual wheelchair
 Wrist brace
 Hearing aid
 Crutch / cane
 Walker
 Other: _____________________________________________________________________
Page 3
VMF, Inc., Proprietary
As of Jan. 5, 2013
Veterans Moving Forward, Inc. is a 501(c)(3) public charity that provides service dogs
to veterans with physical and mental health challenges.
Service Dog Application
Please list all those living with you:
Name
Relationship
(family member,
friend, colleague)
Age
Gender
M/F
Home during
the day
Allergic to
Dogs
M F
 Yes  No
 Yes  No
M F
 Yes  No
 Yes  No
M F
 Yes  No
 Yes  No
M F
 Yes  No
 Yes  No
M F
 Yes  No
 Yes  No
M F
 Yes  No
 Yes  No
M F
 Yes  No
 Yes  No
Have you ever had a dog?  Yes  No If yes, was it a  pet  hunting dog  therapy dog
Have you ever attended dog obedience classes?
 Yes  No If yes, where? ___________________
Are you willing to purchase and use a dog crate?  Yes
Do you consider yourself knowledgeable about dogs?
 No
 Yes  No
What is the average number of hours per day the dog would spend alone? _______________________
Where would the dog be when alone? (VMF dogs have been raised as house dogs) ________________
Where would the dog sleep at night? (VMF dogs have been raised as house dogs) _________________
May a VMF representative visit you in your home for a personal interview?
 Yes  No
How did you hear about VMF’s program? __________________________________________________
___________________________________________________________________________________
Please explain why you want a VMF service dog. You may attach a one-page explanation.



If you are a professional therapist, please describe how a therapy, facility or service dog would
assist in your occupation and the types of clientele you treat.
If you have a physical disability and desire a service dog, please describe your level of physical
limitations, any equipment you use for mobility, and how you believe the service dog would offer
you more independence.
If you have been diagnosed with a traumatic brain injury (TBI), what cognitive limitations do you
have that might impact care of and your relationship with a service dog?
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Page 4
VMF, Inc., Proprietary
As of Jan. 5, 2013
Veterans Moving Forward, Inc. is a 501(c)(3) public charity that provides service dogs
to veterans with physical and mental health challenges.
Service Dog Application
Filing an application does not guarantee receipt of a dog. There is no way to predict if or
when an appropriate dog for you may become available. We will acknowledge receipt of your
application and contact you if we have any questions.
I understand that it is my responsibility to keep VMF informed of changes in my address,
phone numbers and E-mail address, as well as changes in my interest in receiving a
VMF-trained service dog. I understand my application will be kept on file for two years.
Applicant’s Signature: _________________________________ Date: ____________________
Print Name: __________________________________________________________________
Please return this completed application to:
VETERANS MOVING FORWARD, INC., 909 N. Washington St. Suite 410 Alexandria, VA 22314
or scan and create a PDF document and send as an e-mail attachment to admin@vetsfwd.org.
Page 5
VMF, Inc., Proprietary
As of Jan. 5, 2013
Veterans Moving Forward, Inc. is a 501(c)(3) public charity that provides service dogs
to veterans with physical and mental health challenges.