Application for Ambulance Services for Animals in Distress

PDF version


13/1, Third Seaward Road

Valmiki Nagar, Thiruvanmiyur, Chennai - 600 041

Phone : 044-2457 1024, 2457 1025  Fax : 044-2457 1016

E-mail :  Website :


Name of the Scheme : Provision of Ambulance Services for Animals

in Distress



Application form for new proposal



1.       Organisation Name                                             :

          Address                                                               :



          Tel. No.                                                               :

          Fax. No.                                                               :

          Telax No./E-Mail No./Grams                                :

(i)      Name of the Act under which registered              :


(ii)      Registration No. and date of Registration           :         

          (Please attach a photocopy)

2.       Any other Organisation/Instt./Body if applicable, :

          give details



3.       Registration under Foreign Contribution Act       :

4.       Memorandum of Association and Bye-Laws        :

          (Please attach a photocopy)


5.       Name and Address of the Members of the          :

          Board of Management/Governing Body





6.       (i)  Type of Ambulance, such as Heavy/Middle/   :         

              Light carrier, opted for:-

          (ii)   Cost of Ambulance (attach proforma            :

                voucher from the supplier) (maximum

                permissible amount is Rs.3.50 lakhs)

          (iii)  Cost of equipments/modifications (attach     :

                challan form/estimate from a dealer in

                support of the cost) (maximum

                permissible amount is Rs.1.00 lakhs)


7.       The organisation is required to contribute          :

          minimum 10% of total cost of the project


8.       A copy of the Annual cum Progress Report        :

          and Audited Annual Accounts for the

          previous year (s) which should contain the

          Balance Sheet, Income & Expenditure A/c.

          and Receipt and Payment A/c.


9.       Details of Beneficiaries/facilities available with    :

          the Organisation as per Annexure-I


10.     Details of Staff Employed as per                         :

          Annexure II


11.     List of Documents to be attached as per             :

          Annexure - III


12.     List of additional papers, if any given                  :


I/We have read the Scheme and fulfill the requirements and conditions of the Scheme. I/We undertake to abide by all the conditions of the Scheme.

Signature                            :

Name                                  :

Address/Seal                      :

Dated                                  :


Note : Wherever not applicable, specially in case of new organisation, please write N.A.




Name of the Scheme :


Details of Beneficiaries/Facilities available with the Organisation

(i)      Name of the Organisation                                   :

(ii)      Name and address of the Project                        :


(iii)     Year/Previous Year                                             :

Details of Beneficiaries

       Type of animal                        No. of animals                              Male               Female




Details of Facilities available

1.       Whether the Organisation has in-house dispensary?                   Yes/No

2.       Whether the Services of the Veterinary Surgeon available?        Yes/No

          If yes, full time/part time/weekly etc.

3.       Whether First-aid facility to animals available?                             Yes/No

4.       Whether the Organisation have any Bio-gas plant?                     Yes/No

5.       Whether facility for adequate water supply exists?                       Yes/No

          If yes, indicate the source thereof

6.       Whether necessary drainage system exists?                                Yes/No

7.       Whether the organisation has got necessary resources to

            maintain the animal shelter. If yes, give details            Yes/No

Annexure II


Name of the Scheme :


Details of the Staff Employed

Part I (Previous Year)

(i)      Name of the organisation           :

(ii)      Name and address of the Project :

(iii)     Year


  Sl.         Name and            Educational             Date of                  Period for           Salary per         Total        Remarks

                 Address             Qualification      Appointment       which employed         month       salary paid          

                                                                                                            during the year                              during the













Part II (Current Year)

(i)       Only notify change from the previous year

(ii)      In case there is no change in the part I in the previous year please clarify as follows:

             “No change in staff particulars from the previous years.


The list of documents required to be submitted for the Scheme for Ambulance Services for Animals in Distress

1) Application in prescribed proforma;
2) Details of Beneficiaries – Facilities available with the AWO – Annexure I.
3) Details of Staff Employed- Annexure II.
4) Detailed proposal and its justifications alongwith gist of activities undertaken and assets required.
5) Photocopy of Registration.
6) Memorandum of Association showing ‘animal welfare’ one of its objectives duly certified by the Gazetted Officer (or) Notary Public, if the organization is not recognized by the Board.
7) Type and estimate of proposed ambulance.
8) Proforma voucher from the supplier of the ambulance vehicle mentioning the cost of the vehicle.
9) Challan form / estimate from a dealer in support of the cost of the equipments/modifications in the vehicle.
10) List of Governing Body.
11)Audited Accounts of last three years duly certified by a Chartered Account i.e., 1.Audit Report, (b) Balance Sheet, (c) Receipt & Payment Account and    (d) Income & Expenditure Account.
12)Details of financial assistance, if any, received from any other agency for this purpose.
13) Details of Veterinary Doctor/Para Vety. name, full address, Veterinary Council Registration number and  full time or part time & assistance staff with AWO
14) Details record for last three years i.e. how many treated and  rescued animals and certified by the Veterinarians. (As per enclosed proforma)                                                          
15) How many emergency calls  were attended last three years.
16) Details record of the rescued of illegal slaughter house animals in last 3 years.            
17) If the organizations does not own the vehicle/ambulance, how does it pick up/rescue the animals.
18) If the AWO already have Ambulance, the details of the vehicle whether purchased from MEF/AWBI grants, when purchased, Number of Kms. the ambulance has completed.
19) Furnish the details if any dispensary exist, what are the veterinary facilities and first aid box or medicines and medical equipment available, give details.
20) To submit the Animal Verification Certificate certified by the Animal Husbandry Department
21) To submit the undertaking for the Ambulance grant