Application Forms

BUSINESS NAME
Business Name
Name
Title
MAILING ADDRESS
Address
City
State	--Select-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Washington D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
LOCATION ADDRESS
Address
City
State	--Select-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Washington D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
County
BUSINESS CONTACT INFORMATION
Business Phone
Home Phone
Fax Number
Website Address
Email
BUSINESS INFORMATION
Type of Ownership: Corporation   Non Profit   Other - Please indicate:
How many years have you been in business?
Federal ID Number:
Present Insurance Carrier:    Exp. Date of Insurance:
Have you had any claims in the past 5 years? Yes No
Annual Revenues:    501 © 3 Status:
LOCATION INFORMATION - WHERE ADMINISTRATIVE WORK IS DONE
Age of Building:   Sq. Feet of Office Space:
Distance to Fire Hydrant:   Distance to Fire Dept.:
Construction of Building: Frame   Brick
VOLUNTEER INFORMATION
Do you have Volunteers? Yes No    If Yes, # of Volunteers:
What kind of training do you provide for your volunteers?
Length of training period for volunteers:
Do you have all volunteers sign a Hold Harmless Waiver? Yes No
Is there a Volunteer Procedure Manual in place? Yes No
Do you require any background experience in the animal care field for volunteers? Yes No
What is the age limitation for volunteers?
Do you require a Parent or Guardian to sign for volunteers under the age of 18? Yes No
Do you require a Parent or Guardian to be present with under age volunteer when doing volunteer duties? Yes No
Do you do obedience training? Yes No
Are animals trained, owned by you? Yes No
Do you offer training to the public? Yes No
If Yes, do you have a Liability Waiver signed? Yes No
Do you offer a Spay/Neuter Program to the public? Yes No
Do you have certified therapy dogs? Yes No   If Yes, how many?
Do you have adoption forms with Hold Harmless Waiver? Yes No
Do you have any people you pay Perdiem? Yes No   1099's Yes No
Do you have any people you sub-contract? Yes No
Do you use pet stores as a source for adoptions? Yes No   If so, please complete the Supplemental Pet Store Application portion of the form below.
Do you operate in more than one state? Yes No   If so, how many?
How many events do you participate in?
Provide a list of events:
EVALUATION PROCEDURES ON RESCUED ANIMALS
How are animals evaluated?
How are animals handled if they show aggression?
Are animals still placed if there is aggression towards People? Yes No   Other Animals? Yes No   Food? Yes No
What procedures are taken if the animal has bitten someone?
Who makes the decision if the animal has to be euthanized?
If you have an animal that is a known biter, do you place it up for adoption? Yes No
Where do you get your animals from who are taken into your rescue? Rescues   Shelters   Private Pet Owners   Puppy Mills   Dog Clubs   Trainers   Kennels
FOSTER CARE INFORMATION
# Foster Care Homes:
How are they evaluated?
Is there an application that foster homes must complete? Yes No
Do you have them sign a Hold Harmless Waiver? Yes No
Is you foster care applicant a volunteer? Yes No
What kind of training is provided for foster homes?
Do you place a dog/cat into foster care before you evaluate for temperament or aggression? Yes No
Do you place your rescue dogs/cats into a foster home who have children? Yes No
If so, what is the age of children?
How much past experience in the animal care field do you require your foster home to have?
When a foster goes on vacation, what happens to the foster dog or cat?
Do you allow your foster home to keep an animal that is unadoptable to the public? Yes No
Application can only be completed and signed by President, Chairman or Executive Director. When your application is sent we will need 3 Year Loss History from your present insurance carrier or if no prior insurance then resumes must be emailed to us. Resumes must show background experience in the animal care field and what they do for a living. All applications must be fully completed and will need to be resubmitted if not completed. This will delay in in you getting a quote in a timely manner. Before coverage is bound we will need copies of Adoption Contract, Hold Harmless Forms, your Foster Care Application and any Procedure Manuals in place. I hereby declare that I agree to above.
SUPPLEMENTAL APPLICATION FOR ORGANIZATIONS WHO USE PET STORES FOR OFF SITE ADOPTIONS
Complete the form below if you use Pet Stores as a source for Adoptions.
Store Name
Address
City
State	--Select-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Washington D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code
Construction of Building: Masonary   Frame
Age of Building:
Distance to Fire Dept:    Distance to Fire Hydrant:
Do you house animals at the store on a full-time basis? Yes No
If Yes, # of Cats:    # of Dogs:
Who maintains the care of the animals?
Do you take animals to the pet store for one day adoptions? Yes No
If Yes, # of Cats:    # of Dogs:
# of Volunteers or Employees who oversee the adoption day:
How often do you do the one day adoptions?
What supervision is provided at the adoptions?
Do you have written procedures in place for volunteers or employees who oversee the adoption? Yes No
What kind of training & education do you provide for your volunteers or employees in regards to "A Safe Adoption Event"?
Are signs posted on cages "Warning to Keep Hands/Fingers Out"? Yes No
Are dogs leashed when outside of cages/crates? Yes No
Is there a designated area roped off to keep the public from interacting with the animals? Yes No
I hereby declare that all information above is correct.
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