(All information contained in this pre-application is confidential)

Applicant Information  *All Fields are REQUIRED*
Name:  
Street/P.O. Box:  
City: , CO Zip:
Phone:  
Best Time to Call:  
Email:  
How did you hear about Canine Partners of the Rockies?


Canine Partners of the Rockies trains several types of assistance dogs. Please check the type of assistance dog for which you are applying (only check one).


Please explain why you are applying for this type of assistance dog.


If you are applying for a service, facilitated service or in-home therapy dog, what condition/disability does the applicant have?


How many years (or months) has the applicant had this condition?


If you are applying for a Therapy Dog to assist you in your work, what is your profession?


Have you ever been convicted of a crime?  Yes       No
If yes, please explain:


Please provide any additional information you would like us to know:


Please check the following:
I am a Colorado resident

The information contained in this Pre-Application is correct and accurate to the best of my knowledge.

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