Animal Rescue Partner Application

2. Animal Rescue Partner Application
4. Organization Name: *
6. Address:*
8. City:*
9. State*
10. Zip Code:
12. Mailing Address:
14. Email Address:*
16. Phone Number:*
17. Primary Contact:*
19. Type of Organization*
    -- Select One --501c (3) Non-Profit Animal Rescue OrganizationService Dog TrainingGovernment Agency
20. List type of Government Agency:
22. What type of animals are you interested in? Please be specific to include: species, breeds, behaviors, or medical issues that you are interested in:
24. Reason for Requesting Transfer:
26. Please attach the following documents:
    • Copy of 501c (3) documents
    • Veterinary Reference - **This letter must be on an official letterhead and have vet or staff member’s signature.**
28. Copy of 501c (3) documents
29. Veterinary Reference Letter
31. CONSENT TO INSPECTION
    I agree to permit Sumter County Animal Services to inspect the organization’s buildings and kennels where transferred animals are housed at any time. The inspection is to ensure that the animals are being properly cared for. Failure to allow inspections will result in termination of the organization’s privileges and ability to transfer animals from Sumter County Animal Services.
    
    By entering my name below and submitting this application, I hereby agree that I am an authorized representative of the organization listed on this application and that I understand and agree to the terms of this agreement and all of the obligations and responsibilities pertaining to the transfer of animals from Sumter County Animal Services. I enter into this application agreement of my own free will and agree to all of the terms and conditions contained herein on behalf of myself, my agents, and the organization that I represent.
33. Enter name below:*
35. AUTHORIZED REPRESENTATIVES
37. Authorized Agent #1 Name:
39. Home Phone:
40. Cell Phone:
41. Work Phone:
43. Driver License #:
44. DOB:
46. Authorized Agent #2 Name:
48. Home Phone:
49. Cell Phone:
50. Work Phone:
52. Driver License #:
53. DOB:
55. Authorized Agent #3 Name:
57. Home Phone:
58. Cell Phone:
59. Work Phone:
61. By entering my name below and submitting this application, I agree that I am an authorized representative of the organization listed on the application and that I hereby appoint the above listed as authorized agents of the organization. I understand that all agents are required to abide by the terms and conditions of the agencies “Rescue Partner Application” and act in a professional manner while visiting Sumter County Animal Services facility and while conducting business via phone, email, mail or in person. Further, I authorize the agents listed above to sign and approve the Sumter County Animal Services Transfer Contract agreement upon the transfer of any animal to the organization. I agree to accept responsibility for the agents listed above and any animals transferred under their authority. I understand that the organization’s privileges and ability to transfer animals may be revoked if any agent of the organization fails to follow the terms and conditions of the application agreement and the Transfer Contract.
63. Enter name below:*
Leave This Blank:


65. 1. Receive an email copy of this form.
66. Email address

    This field is not part of the form submission.

67. Submit

* indicates a required field