Service Dog Certification Registry Application

Email completed form to service@servicedogsc.org
or mail to:
Service Dog SC
930 Rosedale 36
Capitola, CA 95010

Remember to include a clear photo of your dog and payment of $42.50

Handler Name:_______________________________
Address:_______________________________________________
City:__________________________State:_____________Zip:____
Home Phone#:____________________Work#:________________
Email:__________________________________________________

Service Animal Information:

Breed:_________________________________________________
Sex:__________________Age/DOB:________________Color:___
Call Name:_______________________________________ ____
Date placed in service:__________

Primary Functions:____________________________________

Trainer/Instructor Information (If self, use your name)

Name:_________________________________________________
City:________________________________________State:______

I hereby attest that the above named dog functions as a Service
Animal and that the dog is qualified by training, is well behaved in
public and is under the safe control of its handler while working. I
declare under penalty of perjury that the foregoing is true and correct.

__________________________ Signature Date:__________

Office Use Only – Do Not write below this line
____________________________________________

Denied________Approved___________
SDSCREG#______________Date
Issued:______________________