EmailMe Form - Harborside Terrace - Assistance Animal Request Fo

Assistance Animal Request Form

Date submitted. *

MM / DD / YYYY

Owner Information - All required information. *

Owner Name:
Unit #:

I am requesting an accommodation for a:

Service Animal under the Americans with Disability Act (ADA)

Emotional Support Animal under the Fair Housing Act (FHA)

Name of Professional:(therapist, physician, psychiatrist) *

First Last

Street Address: *

City: *

State: *

Zip Code: *

Phone *

### - ### - ####

Due to a physical or mental illness, I have certain limitations regarding social interaction/coping with stress/anxiety, etc. To help alleviate these difficulties, and to enhance my ability to live independently and to fully use and enjoy the dwelling unit I own, a licensed medical professional has prescribed a support animal that will assist me in coping with my disability.

My Animal Name:

Type of Animal:

If other (this field is for approval required):

Attachment:

I have attached the letter from a licensed medical professional, attesting that I have been under his/her care since and in their opinion, I meet the definition of disability under the Americans with Disabilities Act and the Fair Housing Act.

I have uploaded the medical professional letter. *

CONFIRM

Letter from Medical Professional: *

I have attached the current rabies vaccination for this year which identified the animal, breed, color and understand it is my responsibility to submit current rabies vaccination every year. Require this box to be checked always, regardless of animal type. *

CONFIRM

Current Rabies Vaccination: *

I have attached the current Collier County Dog/CAT license for AUTOFILL ANIMALS NAME if DOG and require this box to be checked only if animal type is a dog. *

CONFIRM

Collier County Dog/Cat license: *

Picture of Support Animal: *

I have attached a picture of my animal. *

CONFIRM

Thank you for completing the Assistance Animal Request Form.