MDA Webforms | 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 Address 1 *

Facility Address 2

City *

State *

Zip Code *

zip plus four -

County Required *

Primary Phone *

Phone Type Ext.

Phone 1

Phone Type Ext.

Phone 2

Phone Type Ext.

Phone 3

Phone Type Ext.

Owner Information

Prefix

Last Name *

First Name *

Middle Initial

Suffix

Business Name

Address 1 *

Address 2

City *

State *

County

Zip Code *

zip plus four -

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 Required

Last Name *

First Name *

Title *

At least one representative required

Type of License *

Has your facility gone out of business? Selection Required

Has your facility gone out of business? *

YesNo

CEU Credits

Period Covered

Do you have a license by USDA-REAC? Selection Required

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? Selection Required

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. Selection Required

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

Number of uploads

Signature

I have read and understand the terms and policies.* Required

Legal Name*

Date 04/24/2026

ACFA License/Registration Application