"Rescue Registry Application" - New York

Rescue Registry Application is a legal document that was released by the New York State Department of Agriculture and Markets - a government authority operating within New York.

Form Details:

  • Released on January 1, 2018;
  • The latest edition currently provided by the New York State Department of Agriculture and Markets;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the New York State Department of Agriculture and Markets.

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Download "Rescue Registry Application" - New York

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Date Received / Time and Date stamp here:
DAI-PDLI (01/18)
NEW YORK STATE
DEPARTMENT OF AGRICULTURE AND MARKETS
10B AIRLINE DRIVE; ALBANY, NY 12235
DIVISION OF ANIMAL INDUSTRY
RESCUE REGISTRY APPLICATION
FRONT & BACK OF APPLICATION MUST BE FULLY COMPLETED!
Please submit:
Office Use Only
$100.00 non-refundable annual registration fee.
Receipt No.:
____________________________
Include registration fee by check/money order payable to “NYS Dept. of Agriculture & Markets”.
Amount Received:
$100
Renewal applications must be submitted to the commissioner at least 30 days prior to the
commencement of the next license year.
INSPECTOR(S):
NEW APPLICANT _______
$100
#
RENEWAL APPLICATION
FEE
REGISTRATION
________
FEE $100
FOR REGISTRATION PERIOD EXPIRING
Name of Organization President or Executive Director
Organization Name
Name of Primary Organization Contact
Fed. ID # or Soc. Sec. # (REQUIRED)
This establishment should be categorized as a: (check all that apply)
SPCA
Humane Society
Animal Protective Association
Rescue
Other Incorporated Animal Adoption/Rescue Organization (Please specify) __________________________
Organization Street Address
City
State
Zip
County
Date Organized
Org. Tel #
Org. Fax #
Mailing Address (if different)
Street
City
State
Zip
Attn:
E-mail address
Website URL
NYS Charities Bureau Registration # (REQUIRED)
For foreign or out-of-state organizations:
ATTACHMENTS (ALL DOCUMENTS REQUIRED)
New York State Filing Date:
Attach all of the following documents to this Application:
• Certified certificate of incorporation as a not-for-profit organization in New
Name and Address (Street & No., City, State, Zip) of a New York
York State; and
State Resident upon whom Service of Process may be made:
• Bylaws or other organizational rules, and any amendments; and
• IRS tax exemption determination letter
Enter the NUMBER of dogs and cats taken in, adopted, or otherwise transferred in or out in a calendar year (Jan. 1 – Dec. 31):
#___________ Dogs in
#___________ Dogs out
#___________ Cats in
#___________ Cats out
Enter the number of animals currently harbored (from all locations) at the time of this application:
#___________ Dogs
#___________ Cats
Description of facilities in which animals are housed:
Date Received / Time and Date stamp here:
DAI-PDLI (01/18)
NEW YORK STATE
DEPARTMENT OF AGRICULTURE AND MARKETS
10B AIRLINE DRIVE; ALBANY, NY 12235
DIVISION OF ANIMAL INDUSTRY
RESCUE REGISTRY APPLICATION
FRONT & BACK OF APPLICATION MUST BE FULLY COMPLETED!
Please submit:
Office Use Only
$100.00 non-refundable annual registration fee.
Receipt No.:
____________________________
Include registration fee by check/money order payable to “NYS Dept. of Agriculture & Markets”.
Amount Received:
$100
Renewal applications must be submitted to the commissioner at least 30 days prior to the
commencement of the next license year.
INSPECTOR(S):
NEW APPLICANT _______
$100
#
RENEWAL APPLICATION
FEE
REGISTRATION
________
FEE $100
FOR REGISTRATION PERIOD EXPIRING
Name of Organization President or Executive Director
Organization Name
Name of Primary Organization Contact
Fed. ID # or Soc. Sec. # (REQUIRED)
This establishment should be categorized as a: (check all that apply)
SPCA
Humane Society
Animal Protective Association
Rescue
Other Incorporated Animal Adoption/Rescue Organization (Please specify) __________________________
Organization Street Address
City
State
Zip
County
Date Organized
Org. Tel #
Org. Fax #
Mailing Address (if different)
Street
City
State
Zip
Attn:
E-mail address
Website URL
NYS Charities Bureau Registration # (REQUIRED)
For foreign or out-of-state organizations:
ATTACHMENTS (ALL DOCUMENTS REQUIRED)
New York State Filing Date:
Attach all of the following documents to this Application:
• Certified certificate of incorporation as a not-for-profit organization in New
Name and Address (Street & No., City, State, Zip) of a New York
York State; and
State Resident upon whom Service of Process may be made:
• Bylaws or other organizational rules, and any amendments; and
• IRS tax exemption determination letter
Enter the NUMBER of dogs and cats taken in, adopted, or otherwise transferred in or out in a calendar year (Jan. 1 – Dec. 31):
#___________ Dogs in
#___________ Dogs out
#___________ Cats in
#___________ Cats out
Enter the number of animals currently harbored (from all locations) at the time of this application:
#___________ Dogs
#___________ Cats
Description of facilities in which animals are housed:
Has the applicant or any partner, officer, director or stockholder been convicted of, or pleaded guilty to, any violation of any provision of Article 26 or 26A of
New York Agriculture and Markets Law or regulations promulgated hereunder pertaining to humane treatment of animals, cruelty to animals, endangering the
life or health of an animal, or violation of any federal, state, or local law pertaining to the care, treatment, sale, possession, or handling of animals or any
regulation or rule promulgated pursuant thereto relating to the endangerment of the life or health of an animal?
YES
NO
If yes, state the full name of the person______________________________________________________________
Name of Court and its location_________________________________________________________________________________________________
Date of Conviction___________________________________ and attach a “Certificate of Conviction”.
If a “Certificate of Conviction” has been provided and registration issued on a prior application, please check this box
The undersigned applies for Exemption from NYS Pet Dealer status pursuant to §408 Article 26A of the Agriculture and Markets Law of the State of New York
and in support of this application, makes the above statements and agrees to comply with the requirements of Article 26A.
The applicant represents that satisfactory housing, sanitation, feeding and watering, handling, veterinary care, records and practices exist to maintain the
establishment in a clean, sanitary and humane condition and that the cleaning, maintenance and operation of the establishment is such that the dogs and cats are
cared for under Article 26-A of the Agriculture and Markets Law.
The issuance of registration is based upon continued compliance with all requirements associated with the humane care and adoption of dogs and cats directly to
the public as a not-for-profit organization.
Upon approval from the Commissioner, registration will be issued to the applicant and an exemption from the definition of Pet Dealer will be granted. Written
approval will be provided by the Commissioner along with a Pet Dealer Exemption Identification Number, which is to be conspicuously displayed on the registrant’s
websites, publications, or advertisements made to the public.
I understand the statements made in this application will be accepted, for all purposes, as the equivalent of an Affidavit.
In addition to being a basis for denial or revocation of registration, any false statements made herein are punishable pursuant to Section 210.45 of the Penal
Law of the State of New York.
ORIGINAL SIGNATURE OF AUTHORIZED REPRESNTATIVE
TITLE
DATE
**
APPLICANTS MUST PROVIDE ALL REQUESTED INFORMATION
ALL SHADED AREAS MUST BE FILLED OUT. SHOULD YOU FAIL TO DO SO, YOUR APPLICATION MAY NOT BE PROCESSED.
QUESTIONS? CALL (518) 457-3502 OR WRI TE TO THE ADDRESS ON THE FRONT OF THIS FORM.
AUTHORIZATION AND PURPOSE
*
Disclosure of your federal social security and federal employer identification numbers is mandatory and is authorized by Section 5 of the New York State Tax
Law. This information is collected to enable the Department of Taxation and Finance to identify individuals, businesses and others who have been delinquent in
filing tax returns or may have understated their tax liability and to generally identify persons affected by the Tax Law administered by the Commissioner of
Taxation and Finance and for any other purpose authorized by the Tax Law.
**The authority to solicit the information requested above is found in Section 16 of the Agriculture and Markets Law and in the sections relating to the specific
registration you are seeking. This information is collected to enable the Department to evaluate your application, to determine if the registration should be issued
and to assist in the enforcement and administration of the Agriculture and Markets Law.
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