ASD Registry™ - American Service Dogs™

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. Please complete all required fields and ensure that the Handler Photo and Dog Photo are uploaded!

* = Required Information

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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:

State:

Zip Code:

ACCOUNT INFORMATION

*Email:

*Confirm Email:

DOG INFORMATION

*Dog Name: *Dog Breed:

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

*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:

SECURITY AGREEMENT

Please enter the characters you see above:

	By clicking on the "Submit Information" button below, I certify that I meet the guidelines of the ADA for Service Dogs (SD) or Psychological Service Dogs (PSD) in my application for ASD™ Registry Certification.