Missouri Department of Agriculture

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
Facility Information
Facility Name*
Address 1*
Address 2
City* State*
Zip code*
Primary Phone*
Phone 1
Phone 2
Phone 3
Owner Information/Authorized Representatives
Authorized Representatives
Type of License*
Has your facility gone out of business?*
CEU Credits Period Covered
Do you have a license by USDA-REAC?*
Do you operate or have an interest in, financial or otherwise, any business operation or facility involving dogs & cats at any other locations?*

Operation Involves*

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