Assistance dog request First name* : Last name* : If this request is for a child, names and first names of the parents* : Email* : Phone / Mobile : Your street and number* : Postal code* : City / Town* : Country* : Country Afghanistan Albania Algeria Andorra Angola Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Colombia Comoros Congo (Brazzaville) Congo (Democratic Rep.) Costa Rica Ivory Coast Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau North Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria North Korea Norway Oman Pakistan Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Réunion Romania Russia Rwanda Saint Barthélemy Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino São Tomé and Príncipe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Date of birth* : National number* : Contact person* : Phone / Mobile of contact person : AVIQ number, if you have one : What tasks will be required of the dog?* : Are you : Student Employee Self-employed Job seeker Other You live in a : Apartment without garden Apartment with garden House without garden House with garden What are your daily and regular routines? What might your dog be exposed to?* : Do you own a vehicle? : Yes No Do you have other animals at home? : Yes No If yes, which ones? : What type of disability/illness do you have?* : If it’s not a congenital disability or illness, since when have you been in a disability situation? : You get around using : Manual wheelchair Manual wheelchair Crutches Walker If other, please specify : How does your disability affect your daily life?* : How did you hear about Os'mose?* : Are you willing to come twice a week to the Os'mose center for training? : Yes No Do you authorize Os'mose to collect your data? : Yes No Privacy policy : Yes, I agree with the privacy policy Fields marked with * are required Send my message
