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: Non Profit Corp.   Sole Prop.   Other - Please indicate:
How many years have you been in business?
Federal ID Number:
Present Insurance Carrier:    Exp. Date of Insurance:
Do you have your 501 (3) C Status? Yes No
Have you had any claims in the past 3 years? Yes No
BUILDING INFORMATION
Building 1:
Use of Building:
Construction Type:    Total Sq. Ft:    Year Built:
Replacement Value:    Value of Contents:
If building is over 30 years old, when were updates done? Wiring Year    Roofing Year    Plumbing Year:    Heating Year:
Building 2:
Use of Building:
Construction Type:    Total Sq. Ft:    Year Built:
Replacement Value:    Value of Contents:
If building is over 30 years old, when were updates done? Wiring Year    Roofing Year    Plumbing Year:    Heating Year:
Building 3:
Use of Building:
Construction Type:    Total Sq. Ft:    Year Built:
Replacement Value:    Value of Contents:
If building is over 30 years old, when were updates done? Wiring Year    Roofing Year    Plumbing Year:    Heating Year:
Are any buildings vacant? Yes No    Value of Computers:
If you are a tenant, are you responsible for glass coverage? Yes No
Value of Fencing attached to building:   Unattached:
Is your fencing chain linked? Yes No   Is fencing at least 6 ft? Yes No
Distance to Fire Hydrant:   # Miles to Fire Dept.:
Total Revenues:   # Animals when full:
Do you do training? Yes No
Do you have a Liability Waiver signed? Yes No
Do you offer training to the public? Yes No
Do you have certified therapy dogs? Yes No   If Yes, how many?
Do you have Vets? Yes No   If Yes, are the Employees? Yes No   Contracted? Yes No
Do you have Animal Control Officers? Yes No   If Yes, complete the Animal Control Officers Supplemental Application (listed below)
Is there a crematory on premises Yes No
Do you have an adoption form with a Hold Harmless Waiver? 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 have any people you pay Perdiem? Yes No   1099's Yes No
Do you have any people you sub-contract? Yes No
How many events do you participate in?
Provide a list of events:
ANIMAL CONTROL OFFICERS SUPPLEMENTAL APPLICATION
Please complete this form below only if you indicated you have Animal Control Officers.
Are they Employees? Yes No   Volunteers? Yes No
Do you have a contract with City of Twp for Animal Control? Yes No
Do you contract any Animal Control Officers? Yes No
If Yes, do they have their own professional liability insurance? Yes No
Are any authorized and certified to carry fire arms? Yes No
If your Humane Officers are employees, what procedures do they follow?
State Certification or License required? Yes No
How many hours are required for state certification?
Are continuing education classes required? Yes No
Do you have a procedure manual in place? Yes No
Are officers court appointed? Yes No
Do your Humane Officers have the juristation to seize animals from the premises? Yes No
Is a search warrant required before entering the premises? Yes No
What are your procedures in a hostile situation?
Do your Humane Officers carry firearms? Yes No
List names of your Humane Officers:
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
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?
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
Before coverage is bound we will need copies of the following: 3 Year Loss History, Pictures of Facility, Copies of your Adoption Contract, Hold Harmless Waivers, Foster Care Agreement and any Procedure Manuals. I hereby declare that I agree to above and that all the information entered is correct.
ADDITIONAL POLICIES AVAILABLE IF NEEDED
COMMERCIAL UMBRELLA:
Liability Limit:
COMMERCIAL AUTO:
Liability Limit:      PIP Limit:    Medical:    Uninsured:    Underinsured:    Comprehensive Ded.:    Collision Ded.:
YEAR, MAKE, MODEL, ID#: Enter the Year, Make, Model, and ID# for all vehicles below
Vehicle #1:
Vehicle #2:
Vehicle #3:
Vehicle #4:
Vehicle #5:
Worker Compensation - Federal ID#:
Clerical Class Payroll: Yes No    # FT Emp:   # PT Emp:
Kennel/Vet/Dr. Payroll: Yes No    # FT Emp:   # PT Emp:
DRIVERS LIST
Vehicle Operators including any Volunteers. Include: FULL NAME, DATE OF BIRTH, DRIVERS LIC# and STATE
Driver #1:
Driver #2:
Driver #3:
Driver #4:
Driver #5:
Driver #6:
Driver #7:
Driver #8:
Driver #9:
Driver #10:
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.
Please check the reCaptcha Box.