ASD Registry™ - American Service Dogs™ | Registration Application 2024
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This form is designed to provide a streamlined method for you to apply for registration of
your Service Dog (SD) / Psychiatric Service Dog (PSD).


If approved, you will receive your notification and details within 30 working days following approval.

* = Required Information
2407212046 t: 2407212046
Registration date: 2024-07-21
tRegistration date: 2024-07-21
Start Date: 2024-07-21
tStart Date: 2024-07-21
Expiration Date: 2024-07-21
tExpiration Date: 2024-07-21
Dog Birth Date: 2024-07-21
tDog Birth Date: 2024-07-21
Latest Shots Date: 2024-07-21
tLatest Shots Date: 2024-07-21
Publicsafe_validation Date: 2024-07-21
tPublicsafe_validation Date: 2024-07-21
REGISTRATION INFORMATION
 
*Service Dog Type:
*Application Purpose:

DOG/HANDLER IMAGE VERIFICATION INFORMATION
 
"Submit a headshot image of your dog and handler.
Each image size should be no greater than 250px x 250px"


*Handler Portrait Image Filename
(From Local Computer/Device):



    

 
*Dog Portrait Image Filename
(From Local Computer/Device):

    

 
HANDLER INFORMATION
 
*Handler Name:
*Handler Main Phone Number:
Mobile Number:
 
HANDLER ADDRESS
 
Street: 

City:
 
ACCOUNT INFORMATION
 
 
 
DOG INFORMATION
 
 
Dog Birth Date:
Dog Birth City:
Dog Birth State:
*Spayed / Neutered:
AKC Registered:    AKC Registration Number: 
 
*Services / Actions Dog Is Trained For:
( Be specific in details of what your Service Dog has been trained to do )
 
GENERAL INFORMATION
 
      
   *Veterinarian Phone Number:    
 
:
  :
:
:
 
:
 
SECURITY AGREEMENT
 
Security Image

Please enter the characters you see above:  



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sql at the end is: insert into asd_info ( asd_registration_number, registration_date, active, start_date, payment_info, expiration_date, service_dog_type, application_purpose, handler_name, handler_phone_number, handler_mobile_number, handler_street1, handler_street2, handler_city, handler_state, handler_zip, handler_email1, handler_email2, handler_image, password1, password2, dog_name, dog_breed, dog_birth_date, dog_birth_city, dog_birth_state, microchip1_number, microchip1_provider, microchip1_provider_contact, microchip2_number, microchip2_provider, microchip2_provider_contact, spayedneutered_verification, akc_registered, akc_registration_number, services_trained_for, active_license_number, active_license_city, active_license_state, latest_shots_date, vet_name, vet_address1, vet_address2, vet_city, vet_state, vet_zipcode, vet_phone, medical_conditions_list, dog_hair_color, unique_characteristics, training_status, dog_image, publicsafe_validation_date, publicsafe_validation_company, publicsafe_validation_letter_received, authorization ) values ( '2407212046', '2024-07-21', '', '2024-07-21', '', '2024-07-21', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '2024-07-21', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '2024-07-21', '', '', '', '', '', '', '', '', '', '', '', '', '2024-07-21', '', '', '' )







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