Fillable Service Animal for People with Disabilities Registration Application (North Carolina)

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Service Animal for People with Disabilities Registration Application (North Carolina)

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The Service Animal for People with Disabilities Registration Application (North Carolina) form is 2 pages long and contains:

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Service Animal for People with Disabilities
Registration Application
Please complete the application (page 1) and provide Verification Statement (page 2) to the
service animal trainer/training facility representative to complete and sign. Sign as indicated
on both pages, attach supporting documentation and mail to: NC Division of Vocational
Rehabilitation Services, Attn: Mamie Branch - 2801 Mail Center, Raleigh, NC 27699-2801.
Applicant’s Name:
APPLICANT
First Middle Initial, Last
Parent/Guardian (if under 18 years old):
First Middle Initial, Last
Address:
Street
City State Zip Code
Daytime Phone: ( )
Email Address:
Nature of Your Disability (identify all):
SERVICE ANIMAL
Name of Animal:
Breed: Age:
Name of Trainer or Representative of
Training Facility (if Trainer’s name unknown):
Training Facility/School:
Name
Street Address
City State Zip Code
Phone: ( )
Email Address:
Training Certificate Number (if applicable)*
*A verification statement from the trainer must be
attached indicating (1) that the animal has satisfac-
torily completed the training, (2) a description of
special skills mastered by the animal, and (3) date
of training completion.
Signature of Applicant or Parent/Guardian Date
For oce use only: Tag No. Date Issued
Signature of Designated Agency Personnel Date
Approved Denied
Service Animal for People with Disabilities
Trainer Verification Statement
(Applicant) has applied for registration of his/her service
animal with the State of North Carolina, Department of Health and Human Services.
Applicant’s Address:
Please complete the following:
Street City State Zip Code
Training Facility/School Name:
Address:
Street City State Zip Code
Name of Animal: Breed: Age:
Service Animal-specific skills mastered (attach additional pages if necessary):
Date of Training Completion: Projected Date of Training Completion (if in training):
I certify that all the statements in this applicaiton and any attached documents are true and correct to the best of my
knowledge and belief, and they are made in good faith. I authorize investigation of all statements made in this application. I
understand that false information may be grounds for rejection of this application or revocation of permit if already issued.
Signature of Trainer or Representative of Training Facility Date
I authorize the above information to be supplied to the North Carolina Department of Health and Human Services for the
sole purposes of obtaining a registration for my service animal.
Signature of Applicant or Parent/Guardian Date
Please mail application and verification statement to:
NC Division of Vocational Rehabilitation Services
Attn: Mamie Branch
2801 Mail Center
Raleigh, NC 27699-2801
For more information, call (919) 855-3524
or
email mamie.branch@dhhs.nc.gov
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Service Animal for People with Disabilities Registration Application (North Carolina)

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Completed 23 January 2021

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