ADUC Program Application

Assistance Dog United Campaign
Assistance Dog Provider Application

Organization Information

Program Name: ______________________________________ Abbreviaton: ___________

Address: __________________________________________________________________

City: ___________________________________ State: ___________ Zip: _____________

Telephone: __________________ TDD: _________________ Fax: ___________________

Website: ____________________________________ Email address: _________________


Program Information (check all that apply)
1.	We train Assistance Dogs
		Owned by our assistance dog applicants that
			Live with the applicant during the ____ weeks of training.
			Are boarded at our facility during the ____ weeks of training.
			Live with a foster family during the ____ weeks of training.
			Live with a vounteer/paid (circle one) trainer during the ____ weeks of training.
			Other: __________________________
		That we acquire from
			Our own breeding program.
			Donations of pure breed puppies.
			Donations of pure breed adults.
			Donations of mixed breed puppies.
			Donations of mixed breed adults.
			Shelters/pounds/humane societies.
			Breed rescue organizations.
			Other: __________________________

2.	Puppies that we acquire are raised by
		Foster families.
		Assistance dog applicants.
		Other: __________________________

3.	Vet, food and other costs incurred during the dog's training
		Are the responsibility of and paid for by the assistance dog applicant.
		Are the responsibility of and paid for by our program.
		Other: __________________________

4.	We teach assistance dog applicants
		To train their own dogs (or dogs we acquire for them) by attending
			Group instructional classes at our facility and surroundings.
			Private instruction at our facility and surroundings.
			Private instruction at their home and surroundings.
			Other: __________________________
		To work the dogs that we have acquired and trained by attending
			Group instructional classes at our facility and surroundings.
			Private instruction at our facility and surroundings.
			Private instruction at their home and surroundings.
			Other: __________________________
		To work their own dogs that we previously trained by attending
			Group instructional classes at our facility and surroundings.
			Private instruction at our facility and surroundings.
			Private instruction at their home and surroundings.
			Other: __________________________
		To use their dogs in animal assisted activities and therapy.

5.	For the ____ days of our assistance dog applicant instruction,
		The applicant is required to travel to and reside at our training site,
			The applicant pays for travel, lodging, food expenses.
			Our program pays for travel, lodging, food expenses.
			Other: __________________________
		The trainer is required to travel to and reside at the applicant's locale,
			The applicant pays for the trainer's travel, lodging, food expenses.
			Our program pays for the trainer's travel, lodging, food expenses.
			Other: __________________________

6.	We train or facilitate the following types of assistance dogs
	Service Hearing Guide Social/therapy Other: ______________
7.	The number of successful assistance dogs we have placed is the following
	___ Service ___ Hearing ___ Guide ___ Social/therapy ___ Other: ______________

We do hereby request membership in the Assistance Dog United Campaign and certify the
above information to be true and correct.
This application must be accompanied by your audits and 990's (or tax returns) for the last two fiscal years, together with program placement information, unless this is a new program. If you are not required to submit federal and state returns, submit a statement of income and expenses. Please submit samples of your program marketing materials for our files.

First Name: ________________ Last Name: ________________ Title: ________________

Signature: ______________________________________ Date: ___________________