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The Fidelco Guide Dog Foundation invites you to complete the form below as the first step towards applying for a Fidelco Guide Dog. Once received, the Admissions Department will soon call you to verify your request.

Personal Information
First Name:
Last Name:
Address:
City:
State:
Country:
Zip Code:
Home Phone Number:
Work Phone Number: (NOT Required)	Work Extension:
E-mail Address: (NOT Required)
Please select your age category.	Under 18 18-29 30-49 50-69 70+

Are you employed?	Yes No

What is your job description? (NOT Required)

Background Information
Are you legally blind?	Yes No

Please state the cause of your blindness.

Have you had orientation or mobility training?	Yes No

Are you an independent traveler?	Yes No

Do you travel with a cane?	Yes No

Have you previously owned a guide dog?	Yes No

Where was the previous guide dog trained?

Please provide a brief description of your daily travel routine.
What is your reason for obtaining a Fidelco Guide Dog?
Who completed this form?	Applicant Family Member Friend

How would you like to receive information from Fidelco?	Large Print Floppy Disk Audio CD Email

Who referred you to Fidelco?(NOT Required)


All information received is confidential and is intended for use by the Fidelco Guide Dog Foundation. No information will be shared without written permission.