Fillable Assistance Animal Application

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Assistance Animal Application

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Assistance Animal Application
Montana State University Billings Housing and Residential Life
PLEASE COMPLETE THIS FORM TO REQUEST AN ACCOMMODATION. IF
YOU REQUIRE ASSISTANCE COMPLETING THIS FORM, OR WISH TO
MAKE THE REQUEST ORALLY, PLEASE CONTACT DISABILITY SUPPORT
SERVICES AT (406) 657-2283.
NAME OF RESIDENT: _____________________________
RESIDENCE HALL/FAMILY HOUSING ADDRESS: _____________________________
TELEPHONE NUMBER: _________________________________
1. Please describe the reasonable accommodation you are requesting
2. Please explain why this reasonable accommodation is needed. You need not provide detailed
information about the nature or severity of the disability.
3. If you are requesting permission to have an assistance animal where it is not readily apparent
that the animal is a service animal, please answer the following:
(a) Type of animal (for example, dog or cat): ____________________________
(b) Is the animal required because of a disability? _____Yes _____No
(c) Does the animal for which you are making a reasonable accommodation request
perform work or do tasks for you because of your disability? _____Yes _____No
(d) If the answer to 3(c) is YES:
a. What work or task does the animal perform?
(e) If the answer to 3(c) is NO:
If the animal for which you are making a reasonable accommodation request does not
perform work or do tasks for you because of your disability, but provides emotional
support or ameliorates one or more symptoms or effects of your disability, please submit
a statement from a health or social service professional stating that:
a. You have a disability (i.e., you have a physical or mental impairment that
substantially limits one or more major life activities); and
b. The animal would provide emotional support or other assistance that would
ameliorate one or more symptoms or effects of your disability and how the
animal ameliorates the symptoms or effect.
Please attach such a statement to this application.
4. If you are requesting a physical change to the interior of your unit, please describe the
modifications.
5. If you are requesting a physical change to the exterior of your unit or to a public or common
use area, please describe the modification.
_________________________________ _________________________________
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Assistance Animal Application

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Completed 21 March 2020

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