ACFA License/Registration Application

Please DO NOT include any personal, confidential, and/or sensitive information in your responses on this form (e.g. social security number, credit card information, health information, account number, etc.).

Application Type

Initial ApplicationRenewal

Facility Information


Facility Name*	Facility Name

Address 1*	Facility Address 1
Address 2	Facility Address 2

City*	City	State*	State	Zip code*	Zip Code - Ext

County*	County

Primary Phone*

primary phone	Phone Type	Ext.

Phone 1

Alternate Phone 1	Phone Type	Ext.

Phone 2

Alternate Phone 2	Phone Type	Ext.

Phone 3

Alternate Phone 3	Phone Type	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*

Phone Type Ext.

Alternate Phone 1

Phone Type Ext.

Alternate Phone 2

Phone Type Ext.

Alternate Phone 3

Phone Type Ext.

E-mail Address

Confirm E-mail Address

Authorized Representatives



Last Name

First Name
Title

Type of License*	Type of License

Has your facility gone out of business?*	YesNo

CEU Credits		Period Covered	Period covered

Do you have a license by USDA-REAC?*	YesNo

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

YesNo

Operation Involves*

DogsCatsBoth

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 10/07/2024