Request Application

Client's Name*

First Last

Are you requesting this application for yourself or someone else?*

If you are not requesting this application for yourself, please let us know who it is for.

myself
my child
my partner

Is the client a minor?*

Yes
No

Your Name*

First Last

Address*

This is the address where we will send your application, if you want us to mail an application.

Street Address Address Line 2 City State ZIP Code

Email

We don't require an email address but it will help us get in touch with you if we have any problems getting an application to you, so we highly recommend you provide one.

Enter Email Confirm Email

Phone

Phone 2

What kind of assistance dog are you looking for?*

EENP does not place guide dogs, hearing dogs, or psychiatric service dogs at this time. If you need one of these types of assistance dog, please visit Assistance Dogs International to find an organization making those placements in your area.

Mobility Service Dog
Diabetic Alert Dog
Other Medical Alert Dog
I don't know!

Briefly, what tasks do you hope an assistance dog will help you with?*

Typical tasks include alerting to high or low blood sugar, retrieving dropped items, getting help from another person, or providing balance support.

0 of 300 max characters

Is there anything else we should know?

Please use this space to provide additional information that may be of use to us as we send an application to you. If you have questions about the application process and whether EENP would be able to place an assistance dog with you, please email us with your questions at info@eenp.org or call us at 919-408-7292. We are unable to respond directly to comments in this form.

0 of 300 max characters

How did you hear about EENP?*

Do you want a mailed copy of the application?*

We will provide a link to download a PDF of the application once you submit this form. If you prefer to download and print the application, you can let us know that you don't need to receive a copy of the application by US mail.

I will print my application from the download link and don't need you to mail me a copy
I would like to receive a printed application in the mail

Opt Out of Mailing List

We generally add contact information to our email and mailing list in order to be sure you receive invitations to graduations and events. However, if you would prefer that we not use your contact information for anything other than direct contact about the application process and your request, please let us know here. Regardless of your choice here, we NEVER sell or rent your contact information.

Do not add my postal address to your mailing list
Do not add my email address to your mailing list

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