ASD Registry™ - American Service Dogs™

This form is designed to provide a streamlined method
for you to apply for ASD™ registration of your Service

Dog (SD).

NOTE: If your application is approved, you will receive your notification package
with all appropriate details within 30 business days following date of approval.

Please complete all required fields and ensure that the Handler Photo and Dog Photo are uploaded. Expect this process to take 30 minutes or more to complete.

* = Required Information

ASD APPLICATION #: 2504190415

REGISTRATION INFORMATION

*Application Purpose:

HANDLER INFORMATION

*Handler Name:

*Handler Main Phone Number:

Mobile Number:

HANDLER ADDRESS

Street:

City:

State:

Zip Code:

ACCOUNT INFORMATION

*Email:

*Confirm Email:

DOG INFORMATION

*Dog Name: *Dog Breed:

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: *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.