MDA Webforms | ACFA-License-Registration-Application

Application Type

Initial Application

Renewal

Facility Information

	facility name required
Facility Name*	Facility Name
	address 1 required
Address 1*	Facility Address 1
Address 2	Facility Address 2
	city required

City*	City	State*	State state required	Zip code*	zip code required zip code invalid zip code extension invalid Zip Code - Ext

County*	County

Primary Phone*

phone required phone invalid primary phone	Phone Type type required	Ext.

Phone 1

phone required phone invalid Alternate Phone 1	Phone Type type required	Ext.

Phone 2

phone required phone invalid Alternate Phone 2	Phone Type type required	Ext.

Phone 3

phone required phone invalid Alternate Phone 3	Phone Type type required	Ext.

Owner Information/Authorized Representatives

Prefix

Last Name *

First Name *

Middle Initial

Suffix

Business Name

Address 1*

Address 2

City*

State*

County

Zip Code *

Ext. -

Primary Phone*

* x

Phone Type * Ext.

Alternate Phone 1

* x

Phone Type * Ext.

Alternate Phone 2

* x

Phone Type * Ext.

Alternate Phone 3

* x

Phone Type * Ext.

E-mail Address

Confirm E-mail Address

Authorized Representatives


	last name required
Last Name
	first name required
First Name
Title	title required

Type of License*

Type of License

Has your facility gone out of business?*

Yes

CEU Credits

Period Covered

Period covered

Do you have a license by USDA-REAC?*

Yes

Do you operate or have an interest in, financial or otherwise, any business operation or facility involving dogs & cats at any other locations?*

Yes

Operation Involves*

Dogs

Cats

Both

Upload

Please attach any additional documentation (program of veterinary care, CEU credits, proof of show, non-profit certification, or any other image here).

Upload Name
JPEG , JPG , PDF

Signature

I have read and understand the terms and policies.*

Legal Name*

Date 11/21/2024

ACFA License/Registration Application

Please attach any additional documentation (program of veterinary care, CEU credits, proof of show, non-profit certification, or any other image here).