Assistance Animal Accommodation Request

Animal 1 of 1 — please complete one form for each animal.

Requesting Tenant/Applicant Information

Complex Name(Required)

Unit Number(Required)

Full Name(Required)

First Last

Phone Number(Required)

Email Address(Required)

Animal Information

Species(Required)

Breed(Required)

Animal's Name(Required)

Age(Required)

Has the animal ever been aggressive toward people or other animals?(Required)

Yes

If yes, please explain

Trained Task Verification

Federal guidance prioritizes animals that are individually trained to perform specific work or tasks that mitigate the effects of a disability.

Please describe the specific task(s) the animal is trained to perform to assist you(Required)

Supporting Documentation

Please attach a letter from a licensed healthcare provider who has a genuine clinical relationship with you. This documentation must verify the existence of a disability and the connection between the disability and the trained tasks performed by the animal.

Documentation from your licensed healthcare provider(Required)

Accepted file types: pdf, jpg, jpeg, png, doc, docx, Max. file size: 10 MB.

Vet Records (Breed, Age & Weight, Proof of Spay/Neuter, Vaccination Records)(Required)

Drop files here or

Accepted file types: pdf, jpg, jpeg, png, doc, docx, Max. file size: 10 MB, Max. files: 5.

Full-Sized Color Picture of Animal(Required)

Accepted file types: jpg, jpeg, png, heic, Max. file size: 10 MB.

Certification

Certification(Required)

I certify that the information provided is true and accurate. I understand that Holton Mountain Rentals evaluates each request on an individual basis and that approval of an assistance animal is contingent upon the animal meeting the criteria for a trained assistance animal under federal guidelines. I acknowledge that I have read the HMR Assistance Animal Guidelines and Owner Responsibilities.

Signature(Required)

Signature Date(Required)