UACOA Rescue Verification & Authorization Form

UACOA Rescue Verification & Authorization Form

Verify your rescue organization and designate authorized pickup representatives.
Rescue Organization Information
Rescue Organization Legal Name*
DBA / Operating Name (if applicable)
YesNoPending
EIN / Tax ID Number*
Upload IRS Determination Letter (PDF allowed)

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Year Established*
State of Incorporation*
Website
Social Media Links
Utah Compliance & Licensing
YesNo
Utah Business Registration Number (if applicable)
Utah Department of Agriculture License Number (if applicable)
Other Applicable Rescue Licensing
Upload Current Licenses

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YesNo
NoYes (Explain Below)
Explanation (if applicable)
Primary Rescue Contact
Primary Contact Name*

First NameLast Name
Title / Role*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Secondary Contact (Optional)
Secondary Contact Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Organization Address
Mailing Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Authorized Pickup Representative #1
Full Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email Address*
example@example.com
Role in Rescue*
Driver’s License State
Upload Photo ID

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Authorized Pickup Representative #2 (Optional)
Full Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Role in Rescue
Driver’s License State
Upload Photo ID

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Certification & Compliance
Our organization is a registered 501(c)(3) in good standingOur organization complies with Utah state lawsOur organization is not under investigation for animal cruelty, hoarding, or neglectNo officer/director has been convicted of animal cruelty or neglectWe agree to provide accurate information and update changes
Rescue Capabilities
DogsCatsSmall AnimalsOther
YesNo
Areas You Serve
Authorization
Authorized Representative Name*

First NameLast Name
Title*
By submitting this form, I certify that all information provided is accurate. I understand that this information will be used by shelters to verify rescue eligibility and authorized pickup representatives.

By signing this form, I acknowledge that it is the rescue’s responsibility to contact shelters directly regarding any animal they are interested in rescuing. I also understand that the rescue is responsible for arranging and completing transportation of any animal they agree to pull.

Furthermore, by rescuing an animal, the rescue organization agrees to assume full responsibility for that animal. This responsibility remains with the rescue unless the animal has been legally rehomed to a new owner. In such cases, the rescue must maintain documentation and provide proof of transfer to the new owner upon request.
Electronic Signature*
Date*

MonthDayYear
Date
Should be Empty:

UACOA Rescue Verification & Authorization Form

Rescue Organization Information

Utah Compliance & Licensing

Primary Rescue Contact

Secondary Contact (Optional)

Organization Address

Authorized Pickup Representative #1

Authorized Pickup Representative #2 (Optional)

Certification & Compliance

Rescue Capabilities

Authorization