Application for Illinois Horse Rescue License - Illinois

This Illinois-specific printable "Application for Illinois Horse Rescue License" is a part of the legal paperwork issued by the Illinois Department of Agriculture.

Download the up-to-date PDF by clicking the link below and mail it as per the guidelines provided by the department.

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APPLICATION FOR ILLINOIS HORSE RESCUE LICENSE
Illinois Department of Agriculture
Bureau of Animal Health and Welfare
BUREAU USE ONLY
801 Sangamon Avenue - PO Box 19281
Springfield, Illinois 62794
Approved by: __________________________
Phone: 217/782-6657
Fax: 217/558-6033
Date License Issued: ____________________
License No. ___________________________
Revenue Code: 88
(Please Print)
Name of Facility ____________________________________________________________________________________________
Address _______________________________________________________
City _____________________________________
Zip Code _________________ County ____________________________
Business Phone ____________________________
E-mail Address, if applicable ______________________________________
Fax Number
__________________________________
Current Premise Identification
______________________________________________________________
(If you do not have a Premise ID, the application can be downloaded from www.agr.state.il.us/PremiseID. There is no fee to register your facility.)
Ownership: (Circle one)
Corporation
Partnership
Individual
List below owner(s) name and present address. If a partnership, list name and address of each partner. If a corporation, list name and
address of each director and officer and/or other person authorized to represent or act for the above-designated ownership. If a
municipality or humane society, list name and address of person(s) in charge of operation.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Are all persons listed under “3” above citizens of the United State of America? Yes
No
(If no, state citizenship ___________________________________________________________
Business name and address of all branch location, if any: _____________________________________________________________
__________________________________________________________________________________________
Previous business connections or experience relating to other animal shelters or animal control facilities: _______________________
____________________________________________________________________________________________________________
Name and address of two (2) professional or business references:
1.
____________________________________________________________________________________________________
2.
____________________________________________________________________________________________________
Has any license of the applicant(s) under this Act or any federal, state, county, or local law, ordinance, or regulation, relating to
dealing or handling of dogs, cats, birds, fish, reptiles, or other animals customarily obtained as pets in this State, ever been suspended
or revoked? Yes
No
If yes, please explain: __________________________________________________________________
Has applicant ever been convicted of a felony? Yes
No
If a foreign corporation, partnership, or individual, are you authorized by the Secretary of State to do business in the State of Illinois?
Yes
No
APPLICATION FOR ILLINOIS HORSE RESCUE LICENSE
Illinois Department of Agriculture
Bureau of Animal Health and Welfare
BUREAU USE ONLY
801 Sangamon Avenue - PO Box 19281
Springfield, Illinois 62794
Approved by: __________________________
Phone: 217/782-6657
Fax: 217/558-6033
Date License Issued: ____________________
License No. ___________________________
Revenue Code: 88
(Please Print)
Name of Facility ____________________________________________________________________________________________
Address _______________________________________________________
City _____________________________________
Zip Code _________________ County ____________________________
Business Phone ____________________________
E-mail Address, if applicable ______________________________________
Fax Number
__________________________________
Current Premise Identification
______________________________________________________________
(If you do not have a Premise ID, the application can be downloaded from www.agr.state.il.us/PremiseID. There is no fee to register your facility.)
Ownership: (Circle one)
Corporation
Partnership
Individual
List below owner(s) name and present address. If a partnership, list name and address of each partner. If a corporation, list name and
address of each director and officer and/or other person authorized to represent or act for the above-designated ownership. If a
municipality or humane society, list name and address of person(s) in charge of operation.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Are all persons listed under “3” above citizens of the United State of America? Yes
No
(If no, state citizenship ___________________________________________________________
Business name and address of all branch location, if any: _____________________________________________________________
__________________________________________________________________________________________
Previous business connections or experience relating to other animal shelters or animal control facilities: _______________________
____________________________________________________________________________________________________________
Name and address of two (2) professional or business references:
1.
____________________________________________________________________________________________________
2.
____________________________________________________________________________________________________
Has any license of the applicant(s) under this Act or any federal, state, county, or local law, ordinance, or regulation, relating to
dealing or handling of dogs, cats, birds, fish, reptiles, or other animals customarily obtained as pets in this State, ever been suspended
or revoked? Yes
No
If yes, please explain: __________________________________________________________________
Has applicant ever been convicted of a felony? Yes
No
If a foreign corporation, partnership, or individual, are you authorized by the Secretary of State to do business in the State of Illinois?
Yes
No
Business Hours: _____________________________________________________________________________________________
Specify days and hours attendant is on duty to care for animals: ________________________________________________________
Horses
Number at facility: _____________________________________
Maximum capacity: __________________________
Preventative Care and Basic Health Management Check all that apply. (A copy of written program or protocol shall be provided
to inspector at the time of initial inspection)
___ Parasite Control Program _______________________________________________________________________________
___ Vaccination Program __________________________________________________________________________________
___ Dental Care __________________________________________________________________________________________
___ Emergency First Aid Kit _______________________________________________________________________________
___ Health Records System ________________________________________________________________________________
___
Injury Protocol
__
_____________________________________________________________________________________
Water (Check all that apply)
Indoor water supply: Buckets: _____ Automatic Waterers: _____ Availability: _____
Outdoor water supply: Tanks: _____ Automatic Waterers: _____ Naturally Occurring: _____
Hand washing facilities available? Yes
No
Pastures and Paddocks (Check all that apply and explain)
___ Available for Turnout __________________________________________________________________________________
___ Access to Feed and Water _______________________________________________________________________________
___ Division of Horses _____________________________________________________________________________________
Fencing
___Type ________________________________________________________________________________________________
Facility (Check all that apply and explain)
___ Barns: _______________________________________________________________________________________________
___ Number and size of Stalls _______________________________________________________________________________
___ Isolation/Quarantine Area _______________________________________________________________________________
___ Run-in Sheds _________________________________________________________________________________________
Horse Transportation
Please describe modes of transportation for horses available at this facility (van, truck trailer, etc.):
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Environment Check all that apply. (A copy of written program or protocol shall be provided to inspector at the time of initial
inspection.)
___ Safety program _______________________________________________________________________________________
___ Sanitation program ____________________________________________________________________________________
___
Bedding program
_
____________________________________________________________________________________
___ Manure removal program _______________________________________________________________________________
___ Fly control program ____________________________________________________________________________________
Veterinarian
Name of current Veterinarian _______________________________________________________________________________
Address ________________________________________________________________________________________________
Telephone ____________________________
Fax _______________________________
Farrier
Name of current Farrier ___________________________________________________________________________________
Address ________________________________________________________________________________________________
Telephone ____________________________
Fax _______________________________
Regular visits (list frequency) ______________________________________________________________________________
Health of Animals at Time of Release
What precautions are taken to assure that each animal for sale or release is healthy and free from any infection or disease?
_______________________________________________________________________________________________________
If animals are accompanied by guarantee, explain provisions of guarantee: __________________________________________
_______________________________________________________________________________________________________
What procedure is used to satisfy complaints? _________________________________________________________________
_______________________________________________________________________________________________________
Records
Is a record of all animals maintained for a minimum of twelve (12) months, including the date received, the source, and the eventual
disposition? Yes
No
Applicant irrevocably consents that actions against him for alleged violations of this Act may be filed in any appropriate court of any county or
municipality of Illinois in which the plaintiff resides or in which some part of the transaction occurred out of which the alleged cause of action arose,
and that process in any action may be served on the applicant by leaving two copies thereof with the Director of Agriculture of the State of Illinois,
who shall forthwith send one copy by registered mail to the applicant at the address shown on this application. Applicant stipulates and agrees that
such service of process shall be taken and held to be valid and binding for all purposes relating to such alleged violations.
By virtue of signing this application, the applicant grants permission to authorized employees of the Department of Agriculture to inspection the
licensed premises during reasonable business hours or at other times deemed necessary by the Department to enforce the laws of the State of Illinois.
Pursuant to the Illinois Administrative Procedures Act, 5 ILCS 100/10-65, and the federal Child Support Act, 42 U.S.C.A. 666, an applicant's social
security number is required to be recorded on an application or a renewal application for a license. A license is defined in the law as any "permit,
certificate, approval, registration, charter, or similar form of permission". However, if the applicant is a business entity that utilizes a Federal
Employer Identification Number, then no social security number is required on the application to comply with the child support laws.
Moreover, Section 10-65(c) of the Administrative Procedures Act requires the following: "Each agency shall require the licensee to certify on the
application form, under penalty of perjury, that he or she is not more than 30 days delinquent in complying with a child support order. Every
application shall state that failure to so certify shall result in disciplinary action, and that making a false statement may subject the licensee to
contempt of court." However, if the applicant is a business entity that utilizes a Federal Employer Identification Number, then such entity is not
required to make the certifications.
FEIN or Social Security Number: ____________________________________
I certify that the above information is correct.
__________________________
Signature
Date
PLEASE DO NOT SEND CASH: Application must be accompanied by a fee of $25 for each license; the fee for each branch license is $25.00.
Check or money order must be made payable to the Illinois Department of Agriculture, PO Box 19281, Springfield, Illinois 62794-9281.
IMPORTANT NOTICE: This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined under Illinois
Compiled Statues, Ch 225, Par. 606/1 through 605/22. Failure to provide this information shall prevent this form from being processed.
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