"Georgia Licensed Animal Rescue Authorization Form" - Georgia (United States)

Georgia Licensed Animal Rescue Authorization Form is a legal document that was released by the Georgia Department of Agriculture - a government authority operating within Georgia (United States).

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GEORGIA DEPARTMENT OF AGRICULTURE
GEORGIA LICENSED ANIMAL RESCUE AUTHORIZATION FORM
Name of Licensed Animal Shelter ________________________________, License #____________.
Name of Animal Shelter Representative _______________________________________________.
Name Licensed Animal Rescue ___________________________________, License # ___________.
Name of Authorized Individual __________________________________Form of personal I.D. (attach)
*************************************************************************************
As a Corporate Officer of (Name of Georgia Licensed Rescue) ______________________________, I am
attesting that (Name of Authorized Individual) _________________________________, Address
_______________________________________; Phone ______________________; Email (if available)
____________________________ is authorized to obtain animals from this Licensed Animal Shelter on
behalf of (Licensed Animal Rescue) ___________________________________. I also attest that while
such animals are in possession of the authorized person that they will comply with all provisions of the
Georgia Animal Protection Act as outlined in §O.C.G.A. 4-11-1 and the Georgia Animal Protection Act
rules Chapter 40-13-13. This agreement may be terminated at any time for any reason by either party.
In order for the Licensed Rescue organization to terminate this authorization the Animal Shelter
Manager must be provided written notification by the licensed rescue that this agreement has been
terminated within 7 days from the date that the authorized person's privileges have been revoked. In
order for the licensed Animal Shelter to terminate this agreement they must notify the licensed rescue
organization; in writing, within 7 days that authorization to obtain animals has been revoked.
Correspondence may be by email; however, it must be signed and printed by the authorized sender.
This agreement/authorization must be kept on file at the licensed animal shelter and must be made
readily available for inspection by GDA during normal business hours.
*************************************************************************************
X _______________________________________.
Signature (Corporate officer of Licensed Rescue)
X _______________________________________Date
____________.
Signature (Animal Shelter Representative)
X ______________________________________________________ .
Signature (Authorized Person)
This Agreement falls under the requirements of the "Rules of Georgia Department of Agriculture Chapter 40-13-13 "Animal Protection"
section 40-13-13-.04(1)(h) record keeping. Any violation of this rule will result in the issuance of a violation for 40-13-13-.04(1)(h) record
keeping and 40-13-13-.02(9)(b) willful disregard. The Commissioner may refuse to issue or renew or may suspend or revoke a license for willful
disregard or violation of any rule or regulation of the "Rules of the Georgia Department of Agriculture Chapter 40-13-13 Animal Protection".
GEORGIA DEPARTMENT OF AGRICULTURE
GEORGIA LICENSED ANIMAL RESCUE AUTHORIZATION FORM
Name of Licensed Animal Shelter ________________________________, License #____________.
Name of Animal Shelter Representative _______________________________________________.
Name Licensed Animal Rescue ___________________________________, License # ___________.
Name of Authorized Individual __________________________________Form of personal I.D. (attach)
*************************************************************************************
As a Corporate Officer of (Name of Georgia Licensed Rescue) ______________________________, I am
attesting that (Name of Authorized Individual) _________________________________, Address
_______________________________________; Phone ______________________; Email (if available)
____________________________ is authorized to obtain animals from this Licensed Animal Shelter on
behalf of (Licensed Animal Rescue) ___________________________________. I also attest that while
such animals are in possession of the authorized person that they will comply with all provisions of the
Georgia Animal Protection Act as outlined in §O.C.G.A. 4-11-1 and the Georgia Animal Protection Act
rules Chapter 40-13-13. This agreement may be terminated at any time for any reason by either party.
In order for the Licensed Rescue organization to terminate this authorization the Animal Shelter
Manager must be provided written notification by the licensed rescue that this agreement has been
terminated within 7 days from the date that the authorized person's privileges have been revoked. In
order for the licensed Animal Shelter to terminate this agreement they must notify the licensed rescue
organization; in writing, within 7 days that authorization to obtain animals has been revoked.
Correspondence may be by email; however, it must be signed and printed by the authorized sender.
This agreement/authorization must be kept on file at the licensed animal shelter and must be made
readily available for inspection by GDA during normal business hours.
*************************************************************************************
X _______________________________________.
Signature (Corporate officer of Licensed Rescue)
X _______________________________________Date
____________.
Signature (Animal Shelter Representative)
X ______________________________________________________ .
Signature (Authorized Person)
This Agreement falls under the requirements of the "Rules of Georgia Department of Agriculture Chapter 40-13-13 "Animal Protection"
section 40-13-13-.04(1)(h) record keeping. Any violation of this rule will result in the issuance of a violation for 40-13-13-.04(1)(h) record
keeping and 40-13-13-.02(9)(b) willful disregard. The Commissioner may refuse to issue or renew or may suspend or revoke a license for willful
disregard or violation of any rule or regulation of the "Rules of the Georgia Department of Agriculture Chapter 40-13-13 Animal Protection".