Name of Volunteer Conducting Visit *

Date Visit Completed *

Applicant's Name *

Applicant has attended Orientation *

• [ ] Yes, already attended
• [ ] No, planning to attend
• [ ] Not required (Prison dog hosts only)

Please list all adults and children in the home and their ages, and note if any occupants are not present. *

Please indicate who will be the Primary Handler

Select the property type *

• [ ] Single-Family
• [ ] Townhome
• [ ] Apartment