According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless
it displays a valid OMB control number. The estimated burden to complete this form is 15 minutes. The OMB control number for this information collection is
2105-0576. The authority for the collection expires on December 31, 2023.
Warning: It is a Federal crime to make materially false, fictitious, or fraudulent statements, entries, or representations knowingly and
willfully on this form to secure disability accommodations provided under regulations of the United States Department of Transportation
(18 U.S.C. § 1001).
U.S. Department of Transportation Service Animal Air Transportation Form
Service Animal Handler’s Name: Phone:
Service Animal User’s Name
(if different from Handler): Phone:
Service Animal Handler’s Email: Animal’s Name
Description of the Animal (including weight):
Animal Health
[Insert Animal’s Name]
is vaccinated for rabies. Date of last vaccination: Date vaccination expires in the dog:
To my knowledge,
[Insert Animal’s Name]
does not have fleas or ticks or a disease that would endanger people or other animals.
Veterinarian’s Name (si
gnature not required): Phone:
Animal Training and Behavior
[Insert Animal’s Name]
has been trained to do work or perform tasks to assist me with my disability.
Name of Animal Trainer or Training Organization: Phone: _
____________________________________________________ ______________________
__________________________
__________ ______________________
______________________________________ _____________________________
________________________________________________________________________
� ________________ ______ ____________
� _____________________
________
_______________________ ______________________________
� _______________________
______________
______________________ ____________________
� _______________________
[Insert Animal’s Name]
has been trained to behave in a public setting.
� I understand that a properly trained dog remains under the control of its handler. I understand that a properly trained dog does not
act aggressively by biting, barking, jumping, lunging, or injuring people or other animals. It also does not urinate or defecate on the
aircraft or in the gate area.
� I understand that if ___________________
[Insert Animal’s Name]
shows that it has not been properly trained to behave in public, then the airline may treat
_______________
[Insert Animal’s Name]
as a pet by charging a pet fee and requiring _______________
[Insert Animal’s Name]
to be transported in a pet carrier.
� To the best of my knowledge, ___________________
[Insert Animal’s Name]
has not behaved aggressively or caused serious injury to another person/dog.
If you cannot check the box above, please explain: ___________
_____________________________________________________
Other Assurance
� I understand that ___________________
[Insert Animal’s Name]
must be harnessed, leashed, or tethered at all times in the airport and on the aircraft.
� I understand that if _______________
[Insert Animal’s Name]
causes damage, then the airline may charge me for the cost to repair it, as long as the airline
would also charge passengers without disabilities to repair the simil
ar kinds of damage.
� I am signing an official document of the U.S. Department of Transportation. My answers are true to the best of my knowledge. I
understand that if I knowingly make false statements on this document, I can be subject to fines and other penalties.
Signature of the Service Animal Handler: __________________________________ Date: _________________________________
click to sign
signature
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