(A) Organization Name: _______________________________________________________________  

Date of Application:  ________/_________/      2010    

Name and Title of Person Completing Application: ____________________________________________  

Organization Mailing Address: ___________________________________________________________

Street: _____________________________________________________________________________  

City  _________________________________   State _____  Zip ___________________ 

Organization Website: _________________________________________________________________  

Name & Title of Member Organization’s Designated Representative:
 (to act on the organization’s behalf in all NFHS business)

Name: ______________________________________    Title: _________________________________

Work Phone: _______________________   Ext. _____          Cell Phone :  ________________________         

Fax: ______________________      Email: _________________________________________________       
 

            Interest in participating on a member working committee?   __________

(B)  Check one and fill in organization’s total operating budget or expenses:

___  We are a governmental animal care and control OR animal services agency.

Our total operating budget is $_________________       Year ____________  

 

___  We are a non-profit humane organization.

(Include a copy of your IRS determination letter and page 1 of your most recent 990)

Our total expenses are  $ ____________________       Year __________  
(from line 18 of agency’s most recent IRS 990)

Annual One Year Membership Fee from Fee Schedule:  $ ____________________ 

Annual Membership Fee (Three Year Commitment) from Fee Schedule:  $ __________________ 

To be completed by NFHS:

Date Received:                                                                                                        Accepted By: