Service Dog AccessDenial Form

Service Dog Access Denial FormOn this day ____________ at ___:___am/pm, I ___________*gatekeeper*______________________ of ___________*site*____________________________ denied access to *Ms. Michelle XXXXXX* for the sole reason that she was accompanied by her service dog, *Byron*. *Ms. XXXXX* confirmed to me that *Byron* is a service dog, specially trained to assist her with her disability and is not a pet. *Ms. XXXX* also explained to me that it is unlawful to deny her access while she is accompanied by her service dog, as long as she is in compliance with the ADA. This access is also further granted under *(your state statutes here)*. I also understand that this form may be used as evidence of my denial of *Ms. XXXXX* access to my place of business in a court of law.Details:____________________________________________________________________________Site of Access Denial (Include Store Name, Number, Address and Phone Number)_____________________________________ ___________________________________Printed Name of Gatekeeper Denying AccessSignature of Gatekeeper _____________________________________ ___________________________________Name of PWD Signature of PWD______________________________________ ____________________________________Printed Name of WitnessWitness Signature____________________________________________________________________________Witness Contact Information