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
selection required
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
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 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
Select
C-Cell
H-Home
O-Office
Ext.
Phone 1
phone required
phone invalid
Alternate Phone 1
Phone Type
type required
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
Phone 2
phone required
phone invalid
Alternate Phone 2
Phone Type
type required
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
Phone 3
phone required
phone invalid
Alternate Phone 3
Phone Type
type required
Select
C-Cell
F-Fax
H-Home
O-Office
Ext.
Owner Information/Authorized Representatives
Prefix
required
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
required
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.
-
*
x
X
Primary Phone
*
*
x
Phone Type
Select
C-Cell
H-Home
O-Office
*
Ext.
Alternate Phone 1
*
x
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
*
Ext.
Alternate Phone 2
*
x
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
*
Ext.
Alternate Phone 3
*
x
Phone Type
Select
C-Cell
F-Fax
H-Home
O-Office
*
Ext.
E-mail Address
*
x
Confirm E-mail Address
x
email and confirm email do not match
Authorized Representatives
last name required
Last Name
first name required
First Name
Title
title required
Select
President
Vice President
Treasurer/Secretary
Co-owner
Manager
Other
Type of License
*
Type of License
type of license required
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
selection required
Has your facility gone out of business?
*
Yes
No
invalid CEU value(0-50)
select year
CEU Credits
Period Covered
Period covered
Select
2024
2023
selection required
Do you have a license by USDA-REAC?
*
Yes
No
USDA license number required
USDA ID number required
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?
*
Yes
No
Operation Involves
*
Dogs
Cats
Both
selection required
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.*
you must agree to the terms
Legal Name
*
legal name required
Date 12/21/2024
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