🐾 Pet / Emotional Support / Service Animal Application

HMS Companies • Special Services Real Estate Company

⚠️ Animal Application Policy & Restricted Dog Breeds

This application must be completed in full in order for agent to consider any pets, emotional support or service animal(s) that tenant / applicant(s) wish to keep at the referenced property. ANY AND ALL DESIRED ANIMALS must be documented via application, including cats, dogs, birds & or reptiles.

Restricted Dog Breeds (Applies to Pets):

Due to increased liability and insurance coverage issues, we will refuse permission to allow certain pure or mixed breed dog(s) at the rental property as PETS, including: German Shepherd, Pit Bull & Bully mixes, Dobermans & Rottweiler. * Note: This restriction does NOT apply to verified assistance / service animals.

* Photo(s) of animal(s) must be provided at time of application submission, in addition to vet license & vaccine registration. By submitting this form, applicant affirms that applicant does not own or intend to possess any dog of the aforementioned breeds as a PET.

👤 1. Resident & Property Information

Section 1 of 5

Resident / Applicant Full Name *

Property Address *

Telephone Number *

Email Address *

🐾 2. Animal Characteristics & Medical Details

Section 2 of 5

Animal Name *

Type of Animal *

Animal Gender *

Canine / Animal Breed (Be specific, include mixed breeds)

Is Animal Licensed?

License #

Duration of Ownership

Present Age (Approx)

Present Weight (lbs)

Is Animal Full Grown?

Anticipated Mature Weight (lbs)

Shots / Vaccines Current?

Is Animal Spayed / Neutered?

Any Behavioral "INCIDENTS"?

Any Physical Alterations or Distinguishing Characteristics?

⚖️ 3. Animal Classification & Assistance Animal Terms

Section 3 of 5

Select Animal Classification *

Assistance / Emotional Support / Service Animal Policy Terms

Hickory Management & our owners abide by state & federal laws associated with "Assistance Animals". In order to qualify as an assistance animal, unless need is readily apparent, Applicant / Tenant MUST provide written communication from a recognized health professional on letterhead signed by the health professional. The communication must state: 1) That the applicant/tenant or household member is a person with a disability; 2) The need for the animal to assist with that specific disability; and 3) That the animal actually assists the person with that disability. * Under no circumstances do we request details regarding the disability itself.

📎 4. Animal Photos & Medical / Vet Documentation

Section 4 of 5

Clear Photo of Animal *

Vet License & Vaccine Records

ESA / Service Documentation (If Applicable)

📜 5. Legal Certification, HIPAA Release & Signature

Section 5 of 5

Applicant Affirmations & Authorization

Applicant understands and agrees to the following:

All information above is true, correct and comprehensive (including comprehensive description of all dog breeds).
Hickory Management is authorized to verify information contained herein (this form constitutes a limited HIPAA release to confirm health professional signatories if applicable).
All intended animals to be granted permission to be on premises are documented on this and/or other animal application(s).
Hickory Management may terminate any contract entered into based upon reliance of any misstatements made herein.
All animal companion acquisitions must be timely to the diagnosis.

I affirm that I do not own or intend to possess any restricted dog breeds as a pet. * I authorize verification of statements and grant limited HIPAA verification release. *

Electronic Signature (Type Full Legal Name) * By typing your name and clicking submit, you execute a legally binding signature.