Ready to Apply? Get an Application Complete this form to receive an application to be partnered with an assistance dog. We will contact you or mail an application to you within a week. 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code EmailWe 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 PhonePhone 2What 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.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.How did you hear about EENP?* internet search ADI website social media a friend an EENP client or volunteer an event 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 ListWe 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 CommentsThis field is for validation purposes and should be left unchanged. Δ
