Rescue Shelter etc App

Page 1 of 8

Applicant Signature: Date:

RHODE ISLAND

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 6 December 2020)

FAQs and Guidance & Inst

ructions: Application for Rescues, Shelters, etc. (updated for 2020)

APPLICATION YEAR: ______ Check one: _____ NEW _____RENEWAL

APPLICANT INFORMATION:

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

____________________________________________________________________________________

Name of REGISTRANT Operator/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:

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

(As defined in Part 1.5 of Rules and Regulations Governing the Importation of Domestic Animals (250-RICR-40-05-1))

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

Date Received: ____________________

Entered: __________________________

Reg. Numbers: ________/___________

Approved By: ____________________

Date Approved:____________________

Online Reporting:___________________

NEW Per part 4.9 K of the Rules and Regulations Governing Animal Care Facilities (250-RICR-40-05-4)

applications submitted over 90 days past expiration must be completed as a NEW application, not a Renewal.

NOTE: Incomplete / illegible 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.

age 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 Domestic Animals (250-

RICR-40-05-1) 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 Rhode Island Point of 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): _________________________________________________

___________________________________________________________________________________

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**********

Privately owned, relinquished animals* (Within RI) ____ YES ____NO

Privately owned, relinquished animals* (NOT in RI) ____ YES ____NO

*Enter COMPLETE Source information on Online AT&RS and Rescue Animal Identification Record.

Rhode Island Private Shelter / Entity: ____ YES ____NO

NOTE: RI Licensed Releasing Agencies (LRA’s) are NOT listed as “Known Entities” in the online Animal Tracking & Reporting

System. Movement between LRA’s is recorded as a TRANSFER by the source LRA to the receiving LRA.

Name of RI SHELTER (ENTITY):

Address:

Town / City: State: Zip Code:

Telephone: Email:

Rhode Island Pound / Municipal Animal Control Facility: ____ YES ____NO

Name of RI Facility (ENTITY):

Address:

Town / City: State: Zip Code:

Telephone: Email:

Out-of-State Private Shelter (NOT in RI): ____ YES ____NO

Name of SHELTER (ENTITY):

Address:

Town / City: State: Zip Code:

Telephone: Email:

Out-of-State Municipal/County Animal Control Facility (NOT in RI): ____YES ____NO

State: Zip Code:

Email:

____ YES ____NO

State: Zip Code:

Name of Facility (ENTITY):

Address:

Town / City:

Telephone:

Other:

Name of Facility (ENTITY):

Address:

Town / City:

Telephone:

Page 3 of 8

Email:

age 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 required)

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

age 5 of 8

Applicant Signature: Date:

CATEGORY A REGISTRANTS

PRE IMPORT PROCESSING PLAN

Per Section 1.8 (E) (1) (a) of Rules and Regulations Governing the Importation of Domestic Animals

(250-RICR-40-05-1), “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)

Dog and Cat Importation Manifest NOTE: This is a fillable PDF. All fields must be completed.

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

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 (250-RICR-40-05-4)(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 RHODE ISLAND FACILITY (if “brick and mortar”

facility in RI)

For ALL Category B Entities, provide for approved RI 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)

Location of Cleaning Logs Waste receptacles (covered)

Indoor and outdoor runs or cages Drainage systems

Isolation and/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

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:

RULES and REGULATIONS

-Can be found at the Rhode Island Secretary of State website using the Search feature:

-URL: https://rules.sos.ri.gov/organizations

-Rules and Regulations Governing the Importation of Domestic Animals (250-RICR-40-05-1)

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

Island (250-RICR-40-05-2)

-Rules and Regulations Governing Importation and Possession of Wild Animals (250-RICR-40-05-3)

-Rules and Regulations Governing Animal Care Facilities (250-RICR-40-05-4)

-Rules and Regulations Governing Reportable Animal Diseases and Conditions in the State of Rhode Island (250-

RICR-40-05-11)

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. Updates to Sources, Fosters or changes in Staff must be reported immediately.

Notification** Requirement per Section 1.8 (D) (5) of Rules and Regulations Governing the Importation

of Domestic Animals (250-RICR-40-05-1)

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:

Link: 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 EVERY 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:

Rescue/Shelter/Broker App as of Dec 2020