| Organization/Facility Name: |
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| Your First Name: |
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| Your Last Name: |
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| Organization/facility Address: |
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| Address Street 2: |
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| City: |
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| Zip Code: |
(5 digits) |
| State: |
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| Organization Phone: |
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| Your Phone: |
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| Contact Phone: |
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| Transport Coordinator Email: |
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| Rescue Coordinator Email: |
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| Would you like to: |
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| You are considered: |
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| You are: |
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| Have you been determined a 501(c)3 organization by the IRS: |
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| EIN number: |
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| If applied for, date: |
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| Are you licensed by the IL Dept of Agriculture: |
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| Are all animals spayed/neutered prior to leaving your possetion: |
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| If no, please explain: |
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| Do you have an on staff Veterinarian: |
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| If yes, Veterinarian's name: |
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| If no, (Receiving rescues) please submit a minimum of 2 veterinary references and thier contact information: |
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| Are all animals vaccinated for rabies: |
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| Do you Heartworm test all canines > 6 mos: |
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| Do you FeLv/FIV test all felines > 3 mos: |
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| Are all animals kept current, per age, on core vaccines: |
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| Do you always treat for heartworm disease, parvo virus, bordetella, feline URI: |
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| If no, please explain: |
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| Do you offer a minimum of 72 hour health guarantee on all animals: |
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| Will you unconditionally take animals back: |
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| Do you temperament test: |
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| Do you have a pull/adoption fee: |
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| If yes, please submit amount(s): |
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| (Receiving rescue) Do you reimburse for pull fees: |
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| (Receiving rescue) Do you reimburse for tranport: |
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| Do you offer transport: |
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| Please explain: |
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| Do you accept FeLv/FIV postive felines: |
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I agree that I am an authorized agent of the above named organization/facility. I agree that answers given above are true and will hold true throughout the relationship with IAR. If at any time any of the above shall change, I agree to notify IAR immediatly. I agree to abide by IAR terms within the ralationship and that IAR may terminate at any time. |
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