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Transport Application

Date:December 1, 2007
Name:	Email: (name@domain.com)
Date of Birth :	Do you have any prior experience in dog rescue? If yes, please explain:
Why do you want to assist in transporting Pekingese ? :
Home Telephone:(include area code) Best Time to Call:	Cell:(include area code) Work Telephone:(include area code) FAX:(include area code)
Address: City/Town: State/Prov.: Zip Code: We work only within Connecticut, Delaware, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island and Vermont. Applications submitted from outside these states cannot be considered.
Driver's Licence #:	State License Issued :
Make of Vehicle used for Transport :	Description of Vehicle used for Transport :
License Plate # :
Do you have any outstanding traffic violations ? :
Have you ever been cited for wreckless driving, endangerment or DUI?:
Please list days of the week and times that you would be available for transport :
Are you willing to assist any other rescue groups in transporting animals? :
Please state mileage you would be willing to travel for transport: :
How did you hear about Northeast Pekingese Rescue? :
Are you currently working with any other Rescues? :	If yes, please provide the name, phone number and email address so we may collaborate our efforts:
Please add any information you feel would help us in our decision for approval of transport :

When you click on the buttons below, you are stating your agreement and compliance to our application process.

By checking this box, you have indicated that this is a valid and legal substitution for your written signature on this legal document titled "Pekingese>Transport Application".
By checking this box, you understand that if the information contained herein is found to be false, your application can be refused and any other applications will be considered null and void.
In signing this form, you agree to transport Pekingese to the final destination. All Pekingese in your custody are in the custody of Northeast Pekingese Rescue. You agree to keep the animal in a safe environment in the vehicle and take precautions necessary to avoid loss of the animal in your care. You agree to keep all necessary paperwork involving vetting and health certificates, release agreements and any paperwork or property of the said animal with the animal and give the paperwork to the assigned individual.
In signing this form, you clearly understand and agree that failure to complete transport to designated individuals or foster homes as agreed will result in legal action and charges of theft.

IMPORTANT: Print out a copy of your application in case you experience any computer problems. If you get an error message after you hit the submit button, try refreshing/reloading the page. If that doesn't work, hit the back button on your browser, then click the submit button again.

Your information is about to be sent via unencrypted/unsecured email. If you do not wish to have your information transmitted in this way, please click "Edit" & "Select All" from your browser and copy and paste the information to an email and send to applications@nepekerescue.org or print and mail to:

NEPR, Inc.
PO BOX 11
Dover PA
17315

Please click "Submit" button only once. Please be patient after hitting submit button, it may take a few minutes to receive confirmation message on your screen.

Questions or Comments? Email us! Info@NEPekeRescue.org

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