Alliance Participating Organization (APO) Application

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Alliance Participating Organization (APO) Application

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Organization Name _________________________________________

Address __________________________________________________

City _________________________ State _____ Zip ______________

Phone _______________________ Fax _________________________

Cell (for internal use only) ___________________________________

E-mail _______________________ Web ________________________

Date of Incorporation (if applicable) ____________________________

Tax Exempt ID Number ______________________________________

Name, Address, and Phone for Veterinarian(s) Used by Your Organization:

_________________________________________________________

__________________________________________________________

I, _____________________________________________, on behalf of

___________________________________________________________, agree to abide by the Terms of Participation for APOs, Dispute Resolution Procedures for APOs, and APO Funding Allocation Procedures attached hereto.

Name _____________________________________________________

Title ______________________________________________________

Signature __________________________________________________

Date ______________________________________________________

•	Please attach a copy of your adoption application and/or agreement and your protocol for checking references prior to placement to this application.
•	Please attach a brief explanation of why you want to join the Mayor's Alliance for NYC's Animals.
•	Please begin to submit copies of the Monthly Adoption Statistics Form for APOs attached hereto no later than the 5th day of each month for the prior month's statistics to the address below.

Please mail your organization's completed application to:

Mayor's Alliance for NYC's Animals, 244 Fifth Avenue, Suite R290, New York, NY 10001-7604, or fax a copy to (212) 591-6383. Call (212) 252-2350 with questions.