Service Dog Certification Registry Application 

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

Remember to include a passport size 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:______________________