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Associate/Affiliate Membership Form
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ABRA Rescue Associate Application
Please complete the form and return it to:
American Boxer Rescue Association
P.O. Box 184
Carmel, IN 46082
1. Rescue Organization: ________________________________________________
Name
________________________________________________
Street Address
________________________________________________
________________________________________________
City, State, Zip
2. Names and Addresses of Principal Officers: (Use attachment if necessary)
Name ________________________________________________
Title ________________________________________________
Street ________________________________________________
________________________________________________
City, State, Zip ________________________________________________
Name ________________________________________________
Title ________________________________________________
Street ________________________________________________
________________________________________________
City, State, Zip ________________________________________________
Name ________________________________________________
Title ________________________________________________
Street ________________________________________________
________________________________________________
City, State, Zip ________________________________________________
3. Principal Point of Contact:
Name ________________________________________________
Title ________________________________________________
Street ________________________________________________
________________________________________________
City, State, Zip ________________________________________________
Phone ____________________ E-Mail _______________________
4. Geographic Service Area: (Use attachment if necessary)
5. Description of Facilities (include foster homes): (Use attachment if necessary)
6. Description of Services and Fees: (Use attachment if necessary)
7. Is your organization part of, affiliated with, or licensed by any other organization? __________
If so, please list them and describe the relationship: (Use attachment if necessary)
8. Rescue History:
A. How long has your organization performed rescue services? ___________________________
B. For each of the Last Three Calendar Years Please Indicate:
Year Number of Dogs Number of Dogs
Processed Placed
(include returns)
1. __________ __________ __________
2. __________ __________ __________
3. __________ __________ __________
9. Adoption and Surrender Contracts:
Please attach copies of your standard adoption and surrender contracts.
10. Recommendations:
Please attach or forward supporting recommendations from veterinarians, humane societies, boxer clubs, or other rescue groups who are familiar with your organization's work.
11. Optional Comments:
Please include any other information or comments you may wish to provide.
12. Application Request and Pledge:
We, the Boxer rescue organization designated in Item 1, hereby apply to the ABRA Board of Directors for ABRA Rescue Associate membership on the basis of the above information, and, by so doing, pledge to adhere to the Bylaws and the Code of Ethics of the American Boxer Rescue Association. We also agree to host site visits by an ABRA representative, from time to time, at the discretion of the ABRA Board of Directors.
_________________________________________
Signature
_________________________________________
Name
_________________________________________
Official Title
_________________________________________
Date
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(Please do not write below this line.)
Certification:
We, the undersigned ABRA officers, hereby certify
__________________________________________________________
as an ABRA Rescue Associate member under the Bylaws of the Association.
____________________________ _____________________
President Date
____________________________ ______________________
Secretary Date |
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