Please complete all sections. Each facility requires a separate form.

1. Entity Information

Entity Information
Entity Name  : 
Mailing Address :
City :  State:  Zip Code: County :
Place of Business
(P.O. Box Not Acceptable)
Entity Telephone :
Entity URL/Website Address      :

Please list the following contacts for your organization
President or Executive Director  : 
Primary On Site Contact :    Telephone :
Mobile :     Email  :
Secondary Contact :
Telephone :     Mobile :

Veterinarian  : 
Address :
Telephone :

Do you maintain a kennel license?  :  Yes     No
Town :     Number of dogs allowed :
Do you have a business license with the town? :
Is your organization :    
Non-Profit registered with the Massachusetts Office of Attorney General
Registered 501(c)(3)

Employee/Volunteer Information
How many employees/volunteers do you normally have?  : 
Average weekly number of staff hours? :

2. Entity Type

Entity Type
Check all that apply
Public pound (government owned) Grooming Facility       Other (please describe)
Shelter Boarding Facility
Rescue Fostering *
Breeder Training
Daycare Breed Rescue
* Note : Those acting and listed as foster homes for a Massachusetts organization that has completed and submitted this form do NOT have to complete this form.

What are the sources of your animals? (Check all that apply)
1. Massachusetts (cities or towns )               :
2. out of state
3. out of country
A. surrendered (owned)       B.strays       C.feral       D.unknown
If source is out of state or country please list      :

How many animals do you handle each month ?  : 
Total adoptions in the last 12 months :

3. Animal Type

Animal Type
Number of Adoptions
Average Adoption Fee
 under 8 weeks
 2 mo. to 6 mo.
 7 mo. to 12 mo.
 over 1 year
 over 5 yrs.

List All Other Animals :

Number of Adoptions
Average Adoption Fee
 under 8 weeks
 2 mo. to 6 mo.
 7 mo. to 12 mo.
 over 1 year
 over 5 yrs.

4. Operation Information

Operation Information
Do you transport animals?  :  Yes       No
Number of animals per month :
Total number of transports per year? :
What type of transport do you use? :  
Car       Truck       Van       Plane
Is this a dedicated animal transport vehicle? : Yes       No
Is the transporter licensed by USDA? : Yes       No

Do you maintain records of :  
Complete description of the animal including unique individual ID Origin information
Transport information Dates of arrival and departure
Transfer information, i.e , to other shelters or to foster care Adoption Information, i.e. ,destination records
Medical records Health Certificates
List of foster care givers Mortalities and method of disposal

Spay/Neuter Protocol : (Check all that apply)
Entity normally restricts its adoptions to animals that have been spayed or neutered prior to adoption.
Entity normally allows animals to be adopted out without being spayed or neutered but accepts a deposit which is refunded upon proof of spay or neuter.
Amount of spay/neuter deposit :
What do you do with the deposit if the animal is not spayed or neutered?
None of the above explain :

The Entity is requesting an inspection of it’s facility by the Division of Animal Health to determine that it is in compliance with Emergency Order 1-AHO-05.
Yes       No