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ACAC Rescue Placement Application
Below you will find our Rescue Placement application. If you are a rescue and
would like to help animals currently at ACAC we ask that you complete our breed
rescue application for our files. You can fax, email, or mail the application.
Organization
Background Information
Organization Name:
Type of Organization (check all that apply):
_No Kill Organization _Private Foster Home _Purebred Rescue
_All Breed Rescue _Independent Rescue _Other (specify):
Is your organization a non-profit 501c3 probationary or permanent Tax Exempt
Organization?
__YES __NO
Please supply the 501c3 Tax Exempt license number or provide a copy of
appropriate documentation for records/verification.
501c3 Tax Exempt license number:
Is your organization affiliated/endorsed by/with any other rescue organizations
or national breed clubs?
(Please list):
Organization Contacts
Name of Director/person in charge of your organization:
Name of contact person in charge of animal intake:
Organization Name:
Mailing Address:
City: State: Zip:
Phone #:
Organization Phone number:
Other contact Number:
Web page URL:
E-mail address:
Organization Policies & Procedures
Breeds/types of animal the rescue accepts:
Do you accept mixed breeds?
__YES __NO
What type of facilities do you provide for rescued animals?
(Please describe in detail):
__Foster Homes __Boarding Kennels __Rescue Facility
How many animals can your rescue accommodate at a time?
Approximately how many animals do you adopt out in a year?
Does your rescue complete spay/neuter procedures before final adoption takes
place?
__YES __NO
Does your rescue adopt animals out unaltered on Spay and Neuter contracts?
__YES __NO
Does your rescue do home checks before final adoption?
__YES __NO
Does your rescue charge an adoption fee?
__YES __NO (How much):_______
What does this fee specifically cover?:
Does your rescue require the adopter to return the animal to your rescue in the
event of an unsuccessful adoption?
__YES __NO
Does your organization euthanize an animal deemed un-adoptable?
__YES __NO
Organization / Veterinarian Partnership
Does your rescue organization work with a specific veterinarian?
__YES __NO
Veterinary Clinic Name:
Treating Veterinarian Name:
Address:
City: State: Zip:
Veterinary Clinic Phone Number:
May we contact the veterinarians?
__YES __NO
Organization Volunteers
Does your organization provide liability insurance to cover
activities/members/volunteers?
__YES __NO
Other Information
Please provide the following (this if for the county that your organization
resides in)
Name of your local county animal control department:
Address:
City: State: Zip:
Phone #:
Does your organization rescue or adopt animals from this department?
__YES __NO
Is your organization licensed or inspected by your local county animal control
department?
__YES __NO
May we contact your local animal control department to verify any information
contained on this application?
__YES __NO
Signature & Terms of Completion
Please review & complete this form and return the application to:
ACAC
Attn: Breed Placement Coordinator
P.O. Box 1131
Standish, MI 48658
(989)-846-4421
Fax: (989)-846-9194
Email: acac_hle@yahoo.com
ACAC reserves the rights to verify any information contained in this
questionnaire and/or inspect the facilities intended for housing rescued
animals. Completion of this questionnaire does not constitute an agreement
between ACAC and your rescue. ACAC reserves the right to decline from
participation in any rescue program or the placement of any animal to an
approved rescue organization. Incomplete applications will not be considered.
Name:
Authorized Signature :
Date:
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