Name of person completing this form Salutation* : ---Dr.Mr.Mrs.Ms. Please indicate if you will be the guardian of the dog, will humanely care for the dog at your home off hours as though it's your pet and responsibly attend to its medical needs or if anyone else will be the dog's guardian? If someone else will, please enter name, email and phone # below.* YesNo Type of clients served* Weekly volume of clients served* Have you ever had a Facility Dog before?* YesNo If yes, please describe the dog - length of service, what it did, successes and failures. What tasks would you like a Putnam Service Dog to do to assist in serving your clients? What personality traits in the dog would help? What size dog would you prefer? Please describe the environment of your facility. Example: Urban, noisy, chaotic, lots of wheel chairs, etc. Please acknowledge your facility is willing to cover the costs to feed, and attend to the medical needs of a Service Dog ($1,500+/yr).* YesNo If No, who will cover these costs? Is there anything else you would like to add?