RI DEM, Division of Agriculture, Registration Application for Animal Rescue, Shelter, Broker, or Remote Sales

Page 1 of 8 Applicant Signature: ________________ Date: ___________

RHODE ISLAND

D

EPARTMENT OF ENVIRONMENTAL MANAGEMENT

DIVISION OF AGRICULTURE

235 Promenade Street, Room 370

Providence, Rhode Island 02908

REGISTRATION APPLICATION FOR ANIMAL RESCUE, SHELTER,

BROKER, OR REMOTE SALES (version 4 December 2017)

Guidance & Instructions: Application for Rescues, Shelters, etc. (updated for 2018)

APPLICANT INFORMATION:

Name of REGISTRANT Entity (Rescue/Shelter etc.): _____________________________________

____________________________________________________________________________________

Name of REGISTRANT Primary contact: _______________________________________________

Rescue/Shelter etc. Address (No P.O. Boxes): ____________________________________________

Town / City: ___________________________________ State: ________ Zip Code: _____________

Telephone: ____________________________________ Fax: ________________________________

Email: ________________________________________ Website: _____________________________

Mail Address (if different from above): ________________________________________________

Town / City: ___________________________________State: ________ Zip Code: _____________

□ New License

□ Renewal

License type

(Select ONE):□Category A □Category B □RI Dogs/Cats ONLY (Does NOT Import)

As defined in Rule 8 of Rules and Regulations Governing the Importation of Animals (10/8/15)

Check which Licensed Releasing Agency (As defined in RI General Law 4-19):

□ RESCUE "Animal rescue" or "rescue" means an entity, without a physical brick-and-mortar facility, that

is owned, operated, or maintained by a duly incorporated humane society, animal welfare society, society for

the prevention of cruelty to animals, or other nonprofit organization devoted to the welfare, protection, and

humane treatment of animals intended for adoption.

□ SHELTER "Animal shelter" means a brick-and-mortar facility that is used to house or contain animals

and that is owned, operated, or maintained by a duly incorporated humane society, animal welfare society,

society for the prevention of cruelty to animals, or other nonprofit organization devoted to the welfare,

protection, and humane treatment of animals.

□ BROKER “Animal Broker” shall mean any third party who arranges, delivers, or otherwise facilitates

transfer of ownership of animal(s), through adoption or fostering, from one party to another, whether or not

the party receives a fee for providing that service and whether or not the party takes physical possession of

the animal(s) at any point.

□ REMOTE SALE “Remote Sale” shall mean the retail purchase of any animal without first having the

opportunity to physically observe or handle the animal, as commonly occurs in internet sales or phone order

sales of animals.

DEM Use Only:

Number: ____________/____________

Approved By: _____________________

Date: ____________________________

Online Reporting: _________________

Fill form out completely even if renewal. NOTE: Incomplete Applications may be rejected

and returned. Fillable PDF Form can be filled out and then printed and submitted via fax, postal

mail, or scanned and emailed. Keep a copy for your records.

Page 2 of 8 Applicant Signature: ________________ Date: ___________

OPERATIONAL PLAN

Rhode Island Point of Contact

Per Section 1.8 (D) (4) Rules and Regulations Governing the Importation of Animals (10/8/15) all entities:

Must identify a Point of Contact who resides within the State of Rhode Island responsible

for maintaining and producing all records that the Department may lawfully request.

A copy of ALL required records must be kept by the designated Point of Contact.

Rhode Island Point of Contact: __________________________________________________

Address (No P. O. Boxes): _____________________________________________________________

Town / City: ___________________________________State: ________ Zip Code: _____________

Telephone: ___________________________________ Fax: ________________________________

Email: _______________________________________ Website: _____________________________

After Hours / Emergency Contact Name / Telephone:

Name: ________________________________________ Phone: _____________________________

Business Hours

(If no “brick and mortar” facility, indicate suitable hours to contact for questions, concerns, trace backs, etc.)

Sun: _____ to _____ Mon: _____ to _____ Tue: _____ to _____ Wed: _____ to _____

Thu: _____ to _____ Fri: _____ to _____ Sat: _____ to _____

Proof of Non-Profit Status is required annually for Rescue and Shelter

Indicate which of the following and provide supporting documentation:

□ Federal 501 (c) 3 □ Rhode Island Domestic Non-Profit □ Other State Domestic Non-Profit

□ Supporting documentation attached demonstrating current status (within last filing year)

Is Rescue/Shelter/Broker/etc. licensed/registered in any other State(s)? □ Yes □ No

Licensing Agency (USDA/ State/County/ Municipal): _____________________________________

Address: __________________________________________________________________________

Town / City: ______________________________________State: ________ Zip Code: __________

Telephone: _______________________________________ Fax: ____________________________

Is ENTITY affiliated with a State / Municipal / County Animal Control? YES □ NO □

If yes, please identify State(s), City(s), Town(s), and /or County(s) and contact information for

Supervising Animal Control Officer(s):__________________________________________________

___________________________________________________________________________________

____________________________________________________________________________________

Page 3 of 8 Applicant Signature: ________________ Date: ___________

SOURCE of Animals:

Use additional pages or lines on page SEVEN if necessary.

PROVIDE UPDATED INFORMATION IMMEDIATELY AS NEW SOURCES ARE ADDED

**********P.O. BOXES ARE NOT ACCEPTABLE**********

1) Privately owned, relinquished animals* (Within RI) YES □ NO □

2) Privately owned, relinquished animals* (NOT in RI) YES □ NO □

*Enter COMPLETE Source information on Online Reporting System and Rescue Animal Identification Record.

3) Rhode Island Private Shelter / Entity: YES □ NO □

Name of RI SHELTER (ENTITY):_____________________________________________________

Address: ___________________________________________________________________________

Town / City: ______________________________________State: ________ Zip Code: ___________

Telephone: _______________________________________ Email: ___________________________

4) Rhode Island Pound / Municipal Animal Control Facility: YES □ NO □

Name of RI Facility (ENTITY):_______________________________________________________

Address: ___________________________________________________________________________

Town / City: ______________________________________State: ________ Zip Code: __________

Telephone: _______________________________________ Email: ___________________________

5) Out-of-State Private Shelter (NOT in RI): YES □ NO □

Name of SHELTER (ENTITY):________________________________________________________

Address: ___________________________________________________________________________

Town / City: ______________________________________State: ________ Zip Code: __________

Telephone: _______________________________________ Email: ___________________________

6) Out-of-State Municipal /County Animal Control Facility (NOT in RI) YES □ NO □

Name of Facility (ENTITY):___________________________________________________________

Address: ___________________________________________________________________________

Town / City: ______________________________________State: ________ Zip Code: ___________

Telephone: _______________________________________ Email: ___________________________

7) Other: ______________________________________________________ YES □ NO □

Name of Facility (ENTITY):___________________________________________________________

Address: ___________________________________________________________________________

Town / City: ______________________________________State: ________ Zip Code: ___________

Telephone: _______________________________________ Email: ___________________________

Page 4 of 8 Applicant Signature: ________________ Date: ___________

List all other EMPLOYEES and/or VOLUNTEERS in Rhode Island

(Use additional pages or lines on page SEVEN as necessary and update as needed)

Entity MANAGER: __________________________________________________________________

Address: ___________________________________________________________________________

Town / City: ______________________________________State: ________ Zip Code: __________

Telephone: _______________________________________ Email: ___________________________

Entity DIRECTOR: _________________________________________________________________

Address: ___________________________________________________________________________

Town / City: ______________________________________State: ________ Zip Code: __________

Telephone: _______________________________________ Email: ___________________________

Additional Employees/Volunteers:

Name Address Phone number

___________________________________________________________________________________

____________________________________________________________________________________

Will ENTITY / SHELTER “Foster out” Animals? YES □ NO □

If yes, please provide names, addresses and phone numbers of those individuals (sub-registrants)

who will provide foster care for animals. Foster homes are subject to inspection when disease or

animal welfare concerns are reported. Also include foster care provider’s affiliations with any

rescue groups or leagues. **Provide updated Foster information as new fosters are added.**

List all current RHODE ISLAND FOSTERS

(Use additional pages or lines on page SEVEN as necessary and update as needed)

Name Address Phone number

____________________________________________________________________________________

Page 5 of 8 Applicant Signature: ________________ Date: ___________

CATEGORY A REGISTRANTS

PRE IMPORT PROCESSING PLAN (**This MUST be submitted ANNUALLY**)

Per Section 1.8 (E) (1) (a) of the Rules and Regulations Governing the Importation of Animals (10/8/15),

“the pre-import processing plan must reference, in detail, the housing conditions, any isolation

procedures, any vaccination procedures, any health screenings, and any disease

testing/treatment/or preventative measures that are taken prior to the animal(s) being transported

into Rhode Island.” (Use additional pages or lines on page SEVEN if necessary)

Housing conditions:

___________________________________________________________________________________

Isolation procedures (**Location and Duration**):

___________________________________________________________________________________

WORK WITH YOUR VETERINARIAN(S) TO PROVIDE THIS INFORMATION:

Vaccination procedures:

Age-based Vaccine schedule: PROVIDE INFO FOR ALL AGES OF CANINES and/or FELINES

Puppies/Kittens: _____________________________________________________________________

Adult Dog/Cats: _____________________________________________________________________

Other: _____________________________________________________________________________

Vaccine Producer(s) and Product(s):

____________________________________________________________________________________

___________________________________________________________________________________

____________________________________________________________________________________

Vaccines Administered by:

____________________________________________________________________________________

Health screenings:

____________________________________________________________________________________

Disease testing/treatment/or preventive measures:

____________________________________________________________________________________

Page 6 of 8 Applicant Signature: ________________ Date: ___________

CATEGORY A REGISTRANTS

USDA / RI LICENSED CARRIER(S): (Use additional pages or lines on page SEVEN if necessary)

1) Name of CARRIER: ___________________________________________________________

Address: ___________________________________________________________________________

Town / City: ______________________________________State: ________ Zip Code: __________

Telephone: _______________________________________ Email: ___________________________

2) Name of CARRIER: ___________________________________________________________

Address: ___________________________________________________________________________

Town / City: ______________________________________State: ________ Zip Code: __________

Telephone: _______________________________________ Email: ___________________________

ALTERNATE TRANSPORT PLAN (For those not intending to use USDA licensed transport)

Rescue’s RI Contact must maintain MANIFEST and provide upon request.

Dog and Cat Importation Manifest

NOTE: This is a fillable PDF. All fields must be completed.

Vehicle Owner / Driver Name: _________________________________________________________

Phone Number: _____________________________________________________________________

Registration (plate # and state): ________________________________________________________

Vehicle Make and Model: _____________________________________________________________

NUMBER OF ANIMALS IN SHIPMENT: ______________________________________________

Features of the vehicle that will ensure adequate climate control in animal compartment: _______

____________________________________________________________________________________

Sanitation protocols for the conveyance: _________________________________________________

____________________________________________________________________________________

CATEGORY B REGISTRANTS:

Mandatory Isolation Facility in Rhode Island (or other approved facility) where dogs/cats will be

held for FIVE (5) Days (minimum of 120 Hours) and examined by a veterinarian before being

placed with Foster or Adopter. DEM Animal Health Section must inspect and approve for

Isolation prior to use. Must be maintained and constructed according to Rules and Regulations

Governing Animal Care Facilities (6/20/16) (If using multiple Facilities, use additional pages)

Name of FACILITY: _________________________________________________________________

Address: ___________________________________________________________________________

Town / City: ______________________________________State: ________ Zip Code: __________

Telephone: _______________________________________ Email: ___________________________

Page 7 of 8 Applicant Signature: ________________ Date: ___________

ATTACH A DETAILED FLOOR PLAN OF FACILITY (unless no “brick and mortar” facility in RI)

For out-of-state Category B Entities, provide plan for approved Rhode Island Isolation Facility.

This diagram should include ALL of the following as applies, including Dimensions:

Main Entrance Interior and exterior doors

Front desk or reception area Windows and vents

Location of rabies and spay/neuter logs Heating and/or cooling system

Location of Dog/Cat Intake/Disposition records Medical treatment room(s) (if applicable)

Cleaning Logs Waste receptacles (covered)

Indoor and outdoor runs or cages Drainage systems

Isolation or quarantine cages/runs/rooms Location of sprinklers or fire extinguishers

Refrigerator and/or freezer Posted emergency evacuation plan or map

Food storage

Lines for ADDITIONAL INFORMATION

____________________________________________________________________________________

NOTE: REGISTRATION expires December 31

st

of each year.

It is the responsibility of the licensee to renew annually. No reminder will be sent.

* No annual fee required

* Use space provided above or additional paper to neatly list any additional information

* Complete form in its entirety (incomplete Applications will be returned until completed)

* Call Div. Of Agriculture /Animal Health with inquiries @ 401-222-2781 x4515

* Fax completed application to 401-222-6047 or

* Scan and email completed application to [email protected] or

* Sign, date as indicated and mail completed application to:

RI Department of Environmental Management

Division of Agriculture / Animal Health Section

235 Promenade St. / Rm. 370

Providence, RI 02908-5767

Signature below attests knowledge and understanding of the following laws and

regulations:

Rhode Island General Laws:

-CHAPTER 4-1 Cruelty to Animals

http://webserver.rilin.state.ri.us/Statutes/TITLE4/4-1/INDEX.HTM

-CHAPTER 4-4 Animal Diseases in General

http://webserver.rilin.state.ri.us/Statutes/TITLE4/4-4/INDEX.HTM

-CHAPTER 4-19 Animal Care

http://webserver.rilin.state.ri.us/Statutes/TITLE4/4-19/INDEX.HTM

Page 8 of 8 Applicant Signature: ________________ Date: ___________

RHODE ISLAND REGULATIONS:

Rules and Regulations Governing Animal Care Facilities (6/20/16)

Rules and Regulations Governing the Importation of Animals (10/8/15)

Rules and Regulations Governing the Prevention, Control and Suppression of Rabies Within the

State of Rhode Island (2/25/16)

See Guidance & Instructions: Application for Rescues, Shelters, etc. for additional Forms,

Laws and Regulations that may apply.

OPERATIONAL PLAN

Any change in the maximum number of animals, housing of animals, types of animals, configuration of

facility, etc., will require an amendment that must be approved by Animal Health prior to the change

being executed. New Sources of Animals, Fosters or changes in staff must be reported immediately.

Notification** Requirement per Section 1.8 (D) (5)

1.8 (D) General Requirements of all entities and carriers:

5. Must notify the Department of all expected shipments of dogs or cats being imported into the state as

to the time and location of the arrival of the shipments. Notification must be received by the Department

no less than 24 hours prior to arrival of the shipment.

**Effective November 2017, the only acceptable format is the “Rescues Import Notification” Form.

**Link to Form online and in Guidance Document:

• Rescue Import Notification Form

URL: http://www.dem.ri.gov/programs/agriculture/documents/rescue_notification.pdf

MANAGER/ DIRECTOR (or equivalent) is responsible for employees, sub-

registrants and/ or volunteers being informed of and understanding laws,

regulations listed above and can attest that to the best of their knowledge, no

employee, volunteer or foster has ever been convicted of animal cruelty or

mistreatment.

***Sign and Date bottom of each page***

Indicate Title(s) if different than those indicated.

Signature of Registrant Primary Contact: ___________________________________

PRINT Name and Title: _____________________________________Date:_________

Signature of Registrant MANAGER: _______________________________________

PRINT Name and Title: _____________________________________Date:_________

Signature of Registrant DIRECTOR: _______________________________________

PRINT Name and Title: _____________________________________Date:_________

2018 Rescue/Shelter/Broker App