Dog Mediation

Please give answers to every question. Feel free to wax eloquent and tell us what is on your mind. If you have questions you may include those in the application in the final section.

Before completing and submitting this application please be sure that you meet the requirements of the Division(s) for which you are applying. If you are not sure ask us first!

First Name *

Last Name *

Date of Application *

Phone *

Email *

Address

City *

State/Region *

Zip/Postal Code *

Country

Business Name *

Website Address *

Have you completed the course?

Course 100% completed Check Yes *

Course partially completed - stop now and complete course

Yes, I have read the Information Packet for Licensure *

Divisions: Check up to three (3)

Enter Description Here

Behavior

Breeding

FDM Service & Library

Handling

Training

Sheltering

Veterinary

Working

Supportive Services

Please list relevant credentials and indicate which division they pertain to if applying for multiple divisions. See document at end of course for details.

Credentials *

Please tell us about all of your education, dog related and other.

Education *

Please tell us about your experience, be specific including time frame, personal, apprenticeships, volunteer etc.

Experience *

Are you willing and able to collaborate as a team player with other licensed members in the division(s) for which you are applying - in conversation, strategizing, project development, and outreach efforts?

Example of a successful collaboration. *

Are you committed and able to "check your ego at the door," and avoid engaging in disparaging criticism of other professionals?

Yes, Agree to Check my Ego *

Describe how you might spread the message of LEGS? *

What else do we need to know about you in order to appreciate all that you have to offer this young movement in the dog behavior industry? What do you see as your unique potential or hopeful contributions to the conversation and paradigm shift in the pet dog world towards a more welfare centric L.E.G.S. model? And further..

What inspires you about Family Dog Mediation? *

BELOW SECTION FOR OFFICE USE ONLY- PLEASE LEAVE REMAINDER OF FIELDS BLANK AND CLICK SEND BUTTON

Status

Completed Course?

Case Work Status

Accepted/Rejected

License/Badge Issued

Division

Date Agreement Sent

Date Payment Link Sent

Date Agreement Signed

Date Payment Received

Pic & Bio On Directory?

Payment Status

Affiliate link sent?

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