2. Rescue Partner Application

4. Name of Organization*
6. Mailing Address*
8. City*
9. State*
10. Zip*
12. Website*
14. Email*
15. Phone Number*
17. Please check which description best fits your organization:*

    1. Government Agency
    2. Rescue Group
    3. Private Organization

    1. Breed Specific Rescue
    2. Private Org. With Government Contract

    1. Sanctuary
    2. Other
19. If you selected Other, please specify below:
21. Is your organization a registered 501c non-profit?*

    1. Yes

    1. No
22. Tax-exempt ID# (if applicable)
24. Number of Years in Operation*
25. Annual Animal Intake*
27. Annual Number of Adoptions*
28. Number of Foster Homes*
30. Animals Accepted*

    1. Dogs
    2. Cats
    3. Rabbits
    4. Small Animals (hamsters, gerbils, ferrets, etc.)

    1. Birds
    2. Reptiles
    3. Pigs
    4. Equine (horses, mules, donkeys, etc.)

    1. Cattle
    2. Chickens
    3. Goats
    4. Other
32. If you selected Other, please specify below
34. Will your organization consider taking animals with medical conditions? *

    1. Yes

    1. No
36. IF YES, upon what grounds is a determination of acceptability made?
38. Will your organization consider taking animals with behavior problems?*

    1. Yes

    1. No
40. IF YES, upon what grounds is a determination of acceptability made?
42. Are senior animals accepted?*

    1. Yes

    1. No
44. Please explain any restrictions:

46. Contact Information:

    By completing this form, you are authorizing the individuals below to act on behalf of your organization under the Linda L. Kelley Animal Shelter Rescue Partner Policies. 

48. Primary Contact Name:*
49. Title:*
51. Cell Number:*
52. Home Phone:
54. Email:*
56. Alternate Contact Name:
57. Title:
59. Cell Number:
60. Home Phone:
62. Email:
64. Alternate Contact Name:
65. Title:
67. Cell Number:
68. Home Phone:
70. Email:

72. References: 

    Please include the veterinary clinic and veterinarian associated with your organization and two (2) other references.

74. Clinic Name:*
76. Veterinarian:*
77. Phone Number:*
79. Email:*
81. #1 Reference Name:*
83. Relationship:*
84. Phone Number:*
86. Email:*
88. #2 Reference Name:*
90. Relationship:*
91. Phone Number:*
93. Email:*

95. I certify that the information given is complete and accurate to the best of my knowledge. I give permission to The Linda L. Kelley Animal Shelter to contact my references. I understand this application does not guarantee acceptance into the Linda L. Kelley Animal Shelter’s Rescue Partner program. I certify that I am authorized to sign this Application on behalf of the aforementioned organization.

97. Electronic Signature:*
98. Date:*
Leave This Blank:


100. 1. Receive an email copy of this form.
101. Email address

     This field is not part of the form submission.

102. Submit Submit and Print

* indicates a required field