Blue Ribbon Breeder 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.).

Licensee/Applicant

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

Do you allow permission to be listed as a member of Blue Ribbon Breeder on Department's website? YesNo

Website

The following field only accepts two alphabetical characters in the first segment.

ACFA License Number The following field only accepts two alphabetical characters in the first segment. *

- Acfa Num Ext

Prerequisites

I am a current member of a Missouri-based breeder association. Selection Required YesNo Breeder Associate Selection Required

I have completed at least 20 hours of continuing education. Selection Required YesNo Education Completed Selection Required

I have not had any violations for the past year. Selection Required YesNo Violations Past Year Selection Requried

My biosecurity plan has been reviewed and approved. Selection Required YesNo BioSecurity Approved Selection Required

Any dogs or kittens sold into commerce are identified by microchip. Selection Required YesNo Microchip Identification Selection Required

Date of Last Inspection. *

Upload Please attach continuing education credits

Please attach continuing education credits.

JPEG , JPG , PDF
Acceptable file types include JPEG , JPG , PDF.

Signature

I have read and understand the terms and policies. Required

Legal Name*

Date 05/18/2026