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Alliance Participating Organization (APO) Application

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Name of Organization: ______________________________

Address: _________________________________________

Phone: __________________________________________

Fax: ____________________________________________

Cell (for internal use only): __________________________

E-mail: __________________________________________

Web Site: ________________________________________

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: __________________________________________

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 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 statistics to the address below.

Please mail your organization's completed application to:

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