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Fallen K9 Submission Form

Supporting K9 units nationwide since 1998.

Fallen K9 Memorial - Line of Duty Death Submission Form

Please complete this form and attach supporting documentation as applicable.

Agency Name*

Agency Address*

County

State

Agency Website

Chief / Sheriff / Director

Agency Point of Contact*

Title/Rank

Email*

Phone Number*

HANDLER INFORMATION

Handler Name*

Handler Rank/Title

Handler Email Address

Handler Phone Number

K9 INFORMATION

K9 Name*

Breed*

Sex

Date of Birth

Date Assigned to Handler

Years of Service*

EoW Date

Age at End of Watch

Date of Incident

Location of Incident

Cause of Death

Primary Assignment

Patrol / Dual Purpose

Narcotics Detection

Explosives Detection

Firearms Detection

Accelerant Detection

Human Remains Detection

Search & Rescue

Tracking / Trailing

Article Detection

Electronic Storage Detection

Currency Detection

Wildlife Detection

Therapy / Wellness

Other

Incident Synopsis*

Biography

Please upload any available supporting documentation (Incident Report, Veterinary Records, Necropsy, etc.)

Supporting Document

K9 Profile Photo

AGENCY CERTIFICATION

Authorized Representative*

Title of Authorized Representative*

I certify that the information provided is accurate to the best of my knowledge.

I understand that submission of this application does not guarantee inclusion in the National Police Dog Foundation Fallen K9 Memorial.

I authorize the National Police Dog Foundation to use the submitted information and photographs for memorial purposes, including the Fallen K9 Memorial website, annual memorial ceremony, Foundation publications, educational materials, printed memorial displays, and official social media.

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The National Police Dog Foundation is registered as a 501(c)(3) nonprofit organization. Contributions are tax deductible to the extent permitted by law. The tax identification number is 77-0496014.

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