Print, fill out and mail to:

Working Dog Foundation
Attention: John Usher
PO Box 515
Portsmouth, NH 03802-515

Office use only:

Name of Handler: ________________________________________

Date Received __________________

Name of Dog: ___________________________________________

Payment Received Y____ N____

Breed of Dog: ___________________________________________

Check, Money Order, Voucher # _______________________

Which Certification?______________________________________

Notes:____________________________________

Date of Test: _________________ Fee:___________

_________________________________________

Address:_______________________________________________

_________________________________________

City:_______________________State_________Zip____________

_________________________________________

Name of Department: ____________________________________

Phone #: _____________E-mail:___________________________