Fillable CALHOUN COUNTY ANIMAL CONTROL Rescue Application

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CALHOUN COUNTY ANIMAL CONTROL Rescue Application

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Form AC219 – Rev1
CALHOUN COUNTY ANIMAL CONTROL
Rescue Application
Calhoun County Animal Control
3605 Mooresville Rd
Anniston, AL 36201
animalcontrol@calhouncounty.org
RESCUE INFORMATION
Rescue Name: ____________________________________________________
Address: ________________________________________________________
City, State, Zip: __________________________________________________
Home Phone: ____________________________________________________
Work Phone: _____________________________________________________
Cell Phone: ______________________________________________________
Email: ___________________________________________________________
POINT OF CONTACT INFORMATION
Name: __________________________________________________________
Address: ________________________________________________________
City, State, Zip: __________________________________________________
Home Phone: ____________________________________________________
Work Phone: _____________________________________________________
Cell Phone: ______________________________________________________
Email: ___________________________________________________________
Form AC219 – Rev1
LOCAL LAW ENFORCEMENT INFORMATION
Department Name: _________________________________________________
Address: ________________________________________________________
City, State, Zip: __________________________________________________
Phone: _________________________________________________________
Has the rescue or any members ever been investigated for animal cruelty or
abuse? Yes ______ No ______
If so please explain (include dates, agency and disposition of case)
________________________________________________________________
________________________________________________________________
________________________________________________________________
VETERINARIAN INFORMATION
Clinic Name: _____________________________________________________
Veterinarian Name: ________________________________________________
Address: ________________________________________________________
City, State, Zip: __________________________________________________
Phone: _________________________________________________________
Form AC219 – Rev1
AUTHORIZED RESCUE PERSONAL INFORMATION
Name: __________________________________________________________
Veterinarian Name: ________________________________________________
Address: ________________________________________________________
City, State, Zip: __________________________________________________
Phone: _________________________________________________________
Email: ___________________________________________________________
Name: __________________________________________________________
Veterinarian Name: ________________________________________________
Address: ________________________________________________________
City, State, Zip: __________________________________________________
Phone: _________________________________________________________
Name: __________________________________________________________
Veterinarian Name: ________________________________________________
Address: ________________________________________________________
City, State, Zip: __________________________________________________
Phone: _________________________________________________________
Email: __________________________________________________________
Email: __________________________________________________________
Form AC219 – Rev1
Has the rescue or any of its members previously been revoked from the IRS?
Yes ______ No ______
If so please explain (include dates, reason and disposition of status)
________________________________________________________________
________________________________________________________________
________________________________________________________________
Do you wish to rescue a: dog _______ cat _________
Do you have an animal preference as far as breed, size, sex, etc?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Form AC219 – Rev1
Please read the following carefully:
The Calhoun County Animal Control will determine the criteria for rescue approval and will decide
which animals will be rescued. Approved rescues may always refuse any specific request due to
timing or other reasons. The Calhoun County Animal Control staff will inform you of any medical
treatments given, the length of stay in the facility and any other information we have.
I have read and understand the statements above. Further, I understand that although the
Calhoun County Animal Control takes reasonable care to screen animals for rescue placement, it
makes no guarantees relating to the animals’ health, behavior, or actions. I understand that I
receive rescue animals at my own risk
and can reject or return any animals for which the Calhoun
County Animal Control provided. I acknowledge that the rescue will be responsible for all State of
Alabama required services (spay/neuter & rabies vaccine) before the animal is placed in an
adopted home. I acknowledge that the Calhoun County Animal Control is not responsible for any
property damage or personal injury suffered by me, members of my rescue, or any third parties
during a rescue placement, and I assume all liability to provide adequate controls to prevent such
damage or injury.
______________________________________________
Signature
______________________________________________
Print Name
_____________________
Date
Management Use Only Do Not Write Below the Line
This application has been __________ Approved __________Denied
This ________________ day of _____________________, 20____.
Signature of Calhoun County Animal Control Representative:
_________________________________________
If denied, list the reason:__________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
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CALHOUN COUNTY ANIMAL CONTROL Rescue Application

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Completed 17 July 2020

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