Application for Accreditation

 If you are providing either temporary or lifetime care for animals, 
or you are an individual concerned about the plight of abused and
homeless animals, we want to hear from you.
MEMORIAL GIFTS
Memorial gifts to ASA's Animal Rescue Fund are urgently needed.  
For more information about this very special form of giving, call 
Vernon Weir, Development Director, 702-804-8562

If you wish to apply for accreditation by ASA, please right click the pages, 
select print, complete the applications and send to:

Application for Accreditation 
c/o The American Sanctuary Association
2340 Sterling Heights, Las Vegas, NV 89134

Please review the policies before submitting this form.

Date:__________

Name of Organization:____________________________

Street address:__________________________________
	
City:____________________
	
State:_______
	  
Zip:________
            
Telephone:__________________
	
Fax:___________________
	
Director:____________________
	
Title:____________________

Email Address:__________________
Web site: ______________________

The purpose of this organization is: (use attachment if necessary)
	




1.)    How long has your organization been in operation?__________

2.)    Please submit a copy of your federal tax exemption letter.

3.)    Please submit a copy of your articles of incorporation and bylaws.

4.)    What are your organization's monthly operating costs?__________

5.)    Briefly describe your source of income:__________________________

6.)    How many employees does your organization have?__________

7.)    How many volunteers does your organization have?__________

8.)    Does your organization provide a safety program for staff and volunteers?_____
        Please attach description.
 9.)    Does you organization have a safety program in case of animal escape or other
         emergency?  Are staff members trained to use capture equipment?  Please attach
         description.       

10.)    Submit your organization's written protocol regarding the use of controlled drugs,
          including emergency procedures when a licensed veterinarian is not present.

11.)    Does your organization keep detailed animal records?_____yes_____no

12.)    Please submit a list of permanently housed species, and a list of species you may be able
           to accept for sanctuary placement in the future.

13.)     Please describe your facility and include photographs or video tape.

14.)     Please submit the name, address and telephone number of attending veterinarians.

15.)     Please submit details of your veterinary care program.

16.)     USDA license #_______________

17.)     State wildlife permit #_______________

18.)     U.S.D.I. Fish & Wildlife Service permit #_______________

19.)     Other permits and numbers you may be holding_______________

20.)     If you have a working relationship with other sanctuaries or animal protection groups,
            please submit the name of these organizations, the name of the person you work with,
            and his/her phone number.

21.)     Please check below the type of educational activities your organization conducts:
            __________Guided tours
            __________Off-site presentations
            __________Special lectures
            __________Radio / TV programs 
            __________Other (please specify)

22.)      Does your organization breed animals?____yes____no
            (if yes, please attach explanation, and include the disposition of these animals).


I the undersigned, swear that the information given in this application is true to the best of my
knowledge.  If accepted as a member of the American Sanctuary Association (ASA), this
organization agrees to abide by its policies and guidelines.  I am aware that if this organization
violates any of the ASA's policies and guidelines, membership may be terminated immediately.

Signature____________________________Date___________

Title___________________________

State of_____________________

County of___________________

Subscribed and sworn to and before me on this_____day of_____year_____

Notary's Payroll Signature____________________

Notary's Typed or Printed Name____________________

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