(A) Organization Name: _______________________________________________________________  

Date of Application:  ________/_________/      2012    

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:  $ __________________ 

Federation member organizations agree to abide by and support the Mission, Values, and Code of Ethics adopted by the NFHS and commit to continuous organizational improvement and collaborative innovation in achieving the Federation's 2020 Vision to end pet homelessness.  Each can be found at www.humanefederation.org.
                                                                                           

X_____________________________________________                    

(signed by your Organization's Designated Representative)

To be completed by NFHS:

Date Received:                                                                                                        Approved By: