Please also review the college's Service Animal Policy. Name(Required) First Last Email(Required) Enter Email Confirm Email Is the animal's handler the same person? Yes Name(Required) First Last Address(Required) Street Address Address Line 2 City State 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 ZIP Code Status(Required) Student Employee Visitor Student ID#(Required)Phone(Required)Service Animal InformationAnimal's Name(Required)Type & Breed(Required)Physical Description(Required)State of Licensure & Lic. Number(Required)Veterinarian(Required)Vet Phone(Required)Vaccination & Immunization History(Required)EligibilityIs the animal required because of a disability?(Required) Yes No What work is the animal trained to perform?(Required)Attestation(Required)I verify that I have read and understand the college’s Service Animal Policy and will abide by its requirements I agree