Shelter - Recipient Application

This is an application for animal shelters to apply for donations from the Rescue Bank Program.

Donors provide wholesome, nutritious food on an as-available basis only. Rescue Bank and recipient organizations are not able to request specific food types (e.g., grain-free) or brands.

Food and supplies (the "Donated Goods") are for the Recipient Group’s use only. They may not be: a) redistributed without the expressed written consent of Rescue Bank, b) sold, rented, or exchanged for other goods or services, nor c) presented for refund.

Each Recipient Organization must complete their own application. Applications work best when viewed and completed using Firefox or Internet Explorer. Submitting this form does not guarantee approval to receive products. Incomplete applications will not be processed.

Organization Name*

Must be the official registered name and not abbreviated

Rescue Bank Affiliate nearest to your location*

Web Site*

Web Site Link to Adoptable Animals*

Direct link required. Please do not just put the word "Petfinder" or www.petfinder.com

Facebook Page

Twitter Account

Non Profit and/or Federal Tax ID#*

Please upload a scanned copy of your IRS Determination Letter*

Upload a File

Address (Not a PO Box)

City*

State*

Zip Code*

E-mail*

Completed by*

Applicant's Position within Organization*

Tel #*

Mission Statement*

Animals reside in*

Foster HomesFacilityBoth

# of dogs adopted past 12 months*

Average monthly need for dog food (lbs)*

# of cats adopted past 12 months*

Average monthly need for cat food (lbs)*

Describe food storage capabilities - include maximum food storage capacity*

Spay/Neuter all animals prior to adoption*

YesNo*

* If no, please explain why

Does your organization have a contract to provide Animal Control Services for any city, county, or municipality? If yes, please explain.

Describe Adoption Programs*

# of employees*

# of active volunteers*

Does the shelter currently participate in a manufacturer sponsored "shelter feeding program"?*

YesNo

If Yes, please list program and frequency.

Has the shelter received "donated" or "low cost" pet food within the past twelve (12) months?*

YesNo

Please list other food sources*

Veterinary Reference - include contact information*

Shelters must provide a Rescue Group Reference - include contact information*

Why is your organization requesting support from Rescue Bank*

If applicable, please provide the top four (4) non-profit rescue groups you allow to pull from your shelter.

Please list your current Board Members and Contact Phone or e-mail for each.*

Authorized Representatives - Please provide at least two.

Full Name*

First and Last NamePosition in Organization

E-mail*

Phone Number*

Area CodePhone Number

Full Name*

First and Last NamePosition in Organization

E-mail*

Phone Number*

Area CodePhone Number

Full Name

First and Last NamePosition in Organization

E-mail

Phone Number

Area CodePhone Number

Full Name

First and Last NamePosition in Organization

E-mail

Phone Number

Area CodePhone Number

1. You are authorized to sign this agreement on behalf of this organization and certify that the information set forth in this application and supporting documentation is correct.

2. You have read and understood the criteria that apply to this application and certify that the group meets each one.

3. The IRS determination letter has not been revoked, canceled or modified.

4. That food shall be protected against dampness, deterioration, and mold or from contamination by insects, birds, rodents or other animals

5. That food spoiled or otherwise contaminated shall not be served.

6. To abide by restrictions or conditions of distribution, if any, imposed by the source of Donation and communicated to Recipient by Donor.

7. Any raw meat provided is not fit for human consumption and shall be used solely for feeding animals.

8. That feeding pet food to ruminant animals is prohibited.

9. To not sell, transfer, trade or barter any Donation or portion thereof in exchange for money, property or services or otherwise allow the items to enter commercial channels.

10. To release both Donor and Donor’s source(s) from any liability arising from the condition of Donation and further agrees to indemnify and hold harmless Donor and its source(s) against any and all damages, losses, claims, causes of action and suits of law or in equity or any obligation whatsoever arising out of or attributed to any action of in connection with Recipients receipt, handling or distribution of Donation.

11. That Rescue Bank may list your organization as a participant in its publications, website or other informational materials but will not sell or disclose non-contact information for any commercial purpose.

12. That goods or services are provided on an "as is" and "as available" basis. Rescue Bank^SM expressly disclaims all warranties of any kind, whether express or implied, including, but not limited to the implied warranties of merchantability or fitness for a particular use or purpose.

13. Your organization grants to Rescue Bank^SM the following: 1) the right to include on its website a link to your organization’s website(s), 2) the right to use any image(s) that you submit to Rescue Bank or that may be recorded by Rescue Bank^SM during or in connection with events that involve both organizations.

14. Permit monitoring, including a site visit if requested, by a Donor representative, as reasonable and necessary to verify that compliance with criteria, receipt, handling and use of Donation conform to this Agreement.

15. Applicant will allow onsite inspection by Rescue Bank representatives within a reasonable period of time (not to exceed 7 days) after request for inspection is made.

16. Applicant grants permission to Rescue Bank and its pet products donors to use information contained in this application for their internal evaluation and response procedures.

17. All Handling Fee payments are to be made payable to the Affiliate Organization or Rescue Bank, as requested, and in no event made to any individual or other organization.

I have read and agree to the terms and conditions.*

Yes

Signature*

Must Type and OK digital Name

Personal e-mail*

Personal Phone Number

Area CodePhone Number

Personal Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

How did you hear about our program? (If you were referred, please list the name of the individual and/or organization)*

Shelter - Recipient Application

By submitting this application you agree and acknowledge the following terms and conditions: