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 Application
Renewal
Facility Information
Facility Name
*
Facility Name
Address 1
*
Facility Address 1
Address 2
Facility Address 2
City
*
City
State
*
State
Select
Missouri
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip code
*
Zip Code
-
Ext
County
*
County
Primary Phone
*
primary phone
Phone Type
Select
C-Cell
H-Home
O-Office
Ext.
Phone 1
Alternate Phone 1
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
Phone 2
Alternate Phone 2
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
Phone 3
Alternate Phone 3
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
Owner Information/Authorized Representatives
Prefix
Select
Mr.
Mrs.
Ms.
Last Name
*
First Name
*
Middle Initial
Suffix
Select
III
IV
Jr.
Sr.
Business Name
Address 1
*
Address 2
City
*
State
*
Select
Missouri
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
County
Select
Adair
Andrew
Atchison
Audrain
Barry
Barton
Bates
Benton
Bollinger
Boone
Buchanan
Butler
Caldwell
Callaway
Camden
Cape Girardeau
Carroll
Carter
Cass
Cedar
Chariton
Christian
Clark
Clay
Clinton
Cole
Cooper
Crawford
Dade
Dallas
Daviess
De Kalb
Dent
Douglas
Dunklin
Franklin
Gasconade
Gentry
Greene
Grundy
Harrison
Henry
Hickory
Holt
Howard
Howell
Iron
Jackson
Jasper
Jefferson
Johnson
Knox
Laclede
Lafayette
Lawrence
Lewis
Lincoln
Linn
Livingston
Macon
Madison
Maries
Marion
McDonald
Mercer
Miller
Mississippi
Moniteau
Monroe
Montgomery
Morgan
New Madrid
Newton
Nodaway
Oregon
Osage
Ozark
Pemiscot
Perry
Pettis
Phelps
Pike
Platte
Polk
Pulaski
Putnam
Ralls
Randolph
Ray
Reynolds
Ripley
Saline
Schuyler
Scotland
Scott
Shannon
Shelby
St. Charles
St. Clair
St. Francois
St. Louis
St. Louis City
Ste. Genevieve
Stoddard
Stone
Sullivan
Taney
Texas
Vernon
Warren
Washington
Wayne
Webster
Worth
Wright
Zip Code
*
Ext.
-
Primary Phone
*
Phone Type
Select
C-Cell
H-Home
O-Office
Ext.
Alternate Phone 1
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
Alternate Phone 2
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
Alternate Phone 3
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
E-mail Address
Confirm E-mail Address
email and confirm email do not match
Authorized Representatives
Last Name
First Name
Title
Select
President
Vice President
Treasurer/Secretary
Co-owner
Manager
Other
Type of License
*
Type of License
Select
Animal Shelter
Boarding Kennel
Carrier
Commercial Breeder
Commercial Kennel
Contract Kennel
Dealer/Broker
Exhibitor
Hobby/Show Licensed
Hobby/Show Registered
Intermediate Handler
Pet Shop
Pet Sitters
Pound/Dog Pound
Rescue
Has your facility gone out of business?
*
Yes
No
CEU Credits
Period Covered
Period covered
Select
2024
2023
Do you have a license by USDA-REAC?
*
Yes
No
Do you operate or have an interest in, financial or otherwise, any business operation or facility involving dogs & cats at any other locations?
*
Yes
No
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).
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Signature
I have read and understand the terms and policies.*
Legal Name
*
Date 10/07/2024
Confirmation Message
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