ASD Registry™ - American Service Dogs™

This form is designed to provide a streamlined method for you to apply for registration of
your Service

Dog (SD) / Psychiatric

Service Dog (PSD).

If approved, you will receive your notification and details within 30 working days following approval.

* = Required Information

2407271003 t: 2407271003
Registration date: 2024-07-27
tRegistration date: 2024-07-27
Start Date: 2024-07-27
tStart Date: 2024-07-27
Expiration Date: 2024-07-27
tExpiration Date: 2024-07-27
Dog Birth Date: 2024-07-27
tDog Birth Date: 2024-07-27
Latest Shots Date: 2024-07-27
tLatest Shots Date: 2024-07-27
Publicsafe_validation Date: 2024-07-27
tPublicsafe_validation Date: 2024-07-27

REGISTRATION INFORMATION

*Service Dog Type:

*Application Purpose:

DOG/HANDLER IMAGE VERIFICATION INFORMATION

"Submit a headshot image of your dog and handler.
Each image size should be no greater than 250px x 250px"

*Handler Portrait Image Filename
(From Local Computer/Device):

*Dog Portrait Image Filename
(From Local Computer/Device):

HANDLER INFORMATION

*Handler Name:

*Handler Main Phone Number:

Mobile Number:

HANDLER ADDRESS

Street:

City:

State:

Zip Code:

ACCOUNT INFORMATION

*Email:

*Confirm Email:

DOG INFORMATION

*Dog Name: *Dog Breed:

Dog Birth Date::
Dog Birth City::
Dog Birth State::

*Spayed / Neutered:

AKC Registered: AKC Registration Number:

*Services / Actions Dog Is Trained For:
( Be specific in details of what your Service

Dog has been trained to do )

GENERAL INFORMATION

*State Licensed In: *City:

*Dog License Number :

*Veterinarian Name: *Veterinarian Phone Number:

*Microchip 1 Registration Provider:

*Microchip 1 Number:

*Microchip 1 Provider Contact:

Microchip 2 Registration Provider:

Microchip 2 Number:

Microchip 2 Provider Contact:

Dog Hair Color:

Unique Visual Characteristics:

SECURITY AGREEMENT

Please enter the characters you see above:

By clicking on the "Submit Information" button below, I certify that I meet the guidelines of the ADA for Service

Dogs (SD) or Psychological Service

Dogs (PSD) in my application for ASD™ Registry Certification.

b1
sql at the end is: insert into asd_info ( asd_registration_number, registration_date, active, start_date, payment_info, expiration_date, service_dog_type, application_purpose, handler_name, handler_phone_number, handler_mobile_number, handler_street1, handler_street2, handler_city, handler_state, handler_zip, handler_email1, handler_email2, handler_image, password1, password2, dog_name, dog_breed, dog_birth_date, dog_birth_city, dog_birth_state, microchip1_number, microchip1_provider, microchip1_provider_contact, microchip2_number, microchip2_provider, microchip2_provider_contact, spayedneutered_verification, akc_registered, akc_registration_number, services_trained_for, active_license_number, active_license_city, active_license_state, latest_shots_date, vet_name, vet_address1, vet_address2, vet_city, vet_state, vet_zipcode, vet_phone, medical_conditions_list, dog_hair_color, unique_characteristics, training_status, dog_image, publicsafe_validation_date, publicsafe_validation_company, publicsafe_validation_letter_received, authorization ) values ( '2407271003', '2024-07-27', '', '2024-07-27', '', '2024-07-27', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '2024-07-27', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '', '2024-07-27', '', '', '', '', '', '', '', '', '', '', '', '', '2024-07-27', '', '', '' )