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
Select
Dr.
Mr.
Mrs.
Ms.
Last Name
*
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
Zip code
*
Zip Code
-
Ext
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.
E-mail Address
Email
Confirm Email
email and confirm email do not match
Confirm E-mail Address
Do you allow permission to be listed as a member of Blue Ribbon Breeder on Department's website?
Yes
No
Website
ACFA License Number
*
-
Acfa Num Ext
Prerequisites
Type Selection
I am a current member of a Missouri-based breeder association.
*
Yes
No
Type Selection
I have completed at least 20 hours of continuing education.
*
Yes
No
Type Selection
I have not had any violations for the past year.
*
Yes
No
Type Selection
My biosecurity plan has been reviewed and approved.
*
Yes
No
Type Selection
Any dogs or kittens sold into commerce are identified by microchip.
*
Yes
No
Date of Last Inspection.
Upload
Please attach continuing education credits.
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Signature
I have read and understand the terms and policies.
Legal Name
*
Date 01/13/2025
Confirmation Message
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