Animal Shelter Registration Form

ANIMAL SHELTER REGISTRATION FORM

Purpose: This form registers an animal shelter or boarding facility with the issuing authority for the purposes of licensing, inspection, and regulatory compliance. Complete all fields accurately. Submission constitutes an attestation that the information provided is true and that the facility will comply with applicable animal health, welfare and public safety requirements.

Facility Identification

New registration Renewal Update to existing record

Registration Number:   Date of Application:

Facility Location & Contact

Facility & Operations Details

Maximum number of animals on site at any time:   Number of indoor kennels/rooms:   Number of outdoor enclosures:

Vet Phone:   Average medical exam cadence:

Policies, Animal Care & Recordkeeping

Rabies vaccination required before adoption: Yes No

Euthanasia performed on-site: Yes No

Staffing, Training & Emergencies

Fees, Payment Terms & Inspections

Registration fee amount: $   Payment due upon submission: Yes

Late fee for overdue registration payment: $   Applied after days past due.

By submitting this form, the registrant consents to scheduled and unscheduled inspections by authorized inspectors for the purpose of verifying compliance. I consent

Term, Termination & Notices

Term of registration begins on and terminates on unless renewed or revoked earlier for cause.

Notice period for voluntary termination or change of ownership: days prior written notice required.

Confidentiality & Records Disclosure

Records maintained by the facility that contain personally identifying information about adopters or donors will be treated as confidential to the extent permitted by law. The registrant acknowledges that records relating to animal health, disposition, and regulatory compliance may be disclosed to authorized agencies or required by subpoena.

Governing Law; Compliance

This registration and all activities conducted under it shall be governed by the laws and regulations of the State of . The registrant shall maintain compliance with all applicable local, state and federal statutes, including animal health, disease control and public safety requirements.

Certifications and Attestations

The undersigned certifies under penalty of perjury that the information submitted herein is true and accurate to the best of their knowledge; that the facility will adhere to the policies described; and that the registrant will permit inspections and provide records as required by authorized officials.

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