REGISTRATION INFORMATION
*Application Purpose :
New Application
Registration Renewal
HANDLER INFORMATION
*Handler Name:
*Handler Main Phone Number:
Mobile Number:
HANDLER ADDRESS
Street:
City:
State :
Choose State
Alabama
Alaska
Alberta
Arizona
Arkansas
British Columbia
California
Canadian
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Foundland
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Nova Scotia
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Is.
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Virgin Islands
Zip Code :
ACCOUNT INFORMATION
*Email :
*Confirm Email :
DOG INFORMATION
*Dog Name :
*Dog Breed :
Mixed
Other
Affenpinscher
Afghan Hound
Airedale Terrier
>Akita
Alaskan Malamute
American Bully
American Bandogge Mastiff
American English Coonhound
American Eskimo Dog
American Hairless Terrier
American Pitbull Terrier
American Staffordshire Terrier
Anatolian Shepherd
Australian Cattle Dog
Australian Sheep Dog
Australian Shepherd
Australian Terrier
Basenji
Basset Hound
Beagle
Bearded Collie
Beauceron
Bedlington Terrier
Belgian Malinois
Belgian Sheepdog
Belgian Tervuren
Bergamasco
Berger Picard
Bernese Mountain Dog
Bichon Frise
Black and Tan Coonhound
Black Mouth Cur
Black Russian Terrier
Bloodhound
Bluetick Coonhound
Boerboel
Border Collie
Border Terrier
Borzoi
Boston Terrier
Bouvier des Flandres
Boxer
Boykin Spaniel
Briard
Brittany
Brussels Griffon
Bull Terrier
Bulldog
Bulldog (American)
Bulldog (English)
Bullmastiff
Cairn Terrier
Canaan Dog
Cane Corso
Catahoula Leopard Dog
Cavalier King Charles Spaniel
Cesky Terrier
Chihuahua
Chinese Crested
Chinese Shar-Pei
Chinook
Chow Chow
Cirneco dell’Etna
Collie
Coton de Tulear
Dachshund
Dalmatian
Dandie Dinmont Terrier
Doberman Pinscher
Dogue de Bordeaux
Dogo Argentino
Dutch Shepherd Dog
English Toy Spaniel
Entlebucher Mountain Dog
Finnish Lapphund
Finnish Spitz
Fox Terrier
Foxhound (American)
Foxhound (English)
French Bulldog
German Pinscher
German Shepherd Dog
Giant Schnauzer
Glen of Imaal Terrier
Goldendoodle
Great Dane
Great Pyrenees
Greater Swiss Mountain Dog
Greyhound
Harrier
Havanese
Ibizan Hound
Icelandic Sheepdog
Irish Setter
Irish Red & White Setter
Irish Terrier
Irish Wolfhound
Italian Greyhound
Jack Russell Terrier
Japanese Chin
Keeshond
Kerry Blue Terrier
Komondor
Kuvasz
Labradoodle
Lacy Dog
Lagotto Romagnolo
Lakeland Terrier
Leonberger
Lhasa Apso
Löwchen
Maltese
Manchester Terrier (Standard)
Manchester Terrier (Toy)
Mastiff
Miniature American Shepherd
Miniature Bull Terrier
Miniature Pinscher
Miniature Schnauzer
Neapolitan Mastiff
Newfoundland
Norfolk Terrier
Norwegian Buhund
Norwegian Elkhound
Norwegian Lundehund
Norwich Terrier
Nova Scotia Duck Tolling Retriever
Old English Sheepdog
Otterhound
Papillon
Parson Russell Terrier
Pekingese
Pembroke Welsh Corgi
Petit Basset Griffon Vendéen
Pharoah Hound
Plott
Pointer
Pointer (German Shorthaired)
Pointer (German Wirehaired)
Polish Lowland Sheepdog
Pomeranian
Poodle
Portuguese Podengo Pequeno
Portugese Water Dog
Pug
Puli
Pumi
Pyrenean Shepherd
Rat Terrier
Redbone Coonhound
Retriever (Chesapeake Bay)
Retriever (Curly-Coated)
Retriever (Flat-Coated)
Retriever (Golden)
Retriever (Labrador)
Rhodesian Ridgeback
Rottweiler
Russell Terrier
Saint Bernard
Saluki
Samoyed
Schipperke
Scottish Deerhound
Scottish Terrier
Sealyham Terrier
Setter (English)
Setter (Gordon)
Setter (Irish)
Shetland Sheepdog
Shiba Inu
Shih Tzu
Siberian Husky
Silky Terrier
Skye Terrier
Sloughi
Soft Coated Wheaten Terrier
Spaniel (American Water)
Spaniel (Clumber)
Spaniel (Cocker)
Spaniel (English Cocker)
Spaniel (English Springer)
Spaniel (Field)
Spaniel (Irish Water)
Spaniel (Sussex)
Spaniel (Welsh Springer)
Spanish Water Dog
Spinone Italiano
Staffordshire Bull Terrier
Standard Schnauzer
Swedish Vallhund
Tibetan Mastiff
Tibetan Spaniel
Tibetan Terrier
Toy Fox Terrier
Treeing Walker Coonhound
Vizsla
Weimaraner
Welsh Corgi (Cardigan)
Welsh Corgi (Pembroke)
Welsh Terrier
West Highland White Terrier
Whippet
White Shepherd
Wirehaired Pointing Griffon
Wirehaired Vizsla
Xoloitzcuintli
Yorkshire Terrier
Dog Birth Date (YYYY-MM-DD):
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
*State Licensed In :
Alabama
Alaska
Alberta
Arizona
Arkansas
British Columbia
California
Canadian
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Manitoba
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Brunswick
New Foundland
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Nova Scotia
Ohio
Oklahoma
Ontario
Oregon
Pennsylvania
Prince Edward Is.
Puerto Rico
Quebec
Rhode Island
Saskatchewan
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Virgin Islands
*City :
*Dog License Number :
*Veterinarian Name :
Veterinarian Phone Number :
*Microchip 1 Registration Provider :
*Microchip 1 Number:
*Microchip 1 Provider Contact :
Microchip 2 Registration Provider :
Microchip 2 Number:
Microchip 2 Provider Contact :
Dog Hair Color:
Unique Visual Characteristics :
I certify that my Service Dog meets the specified criteria to apply for ASD™ Registry Certification for being PublicSafe™ and am aware the application fee is non-refundable.
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