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
required
Select
Dr.
Mr.
Mrs.
Ms.
Last Name
*
last name required
Last Name
First Name
*
first name required
Middle Initial
Suffix
required
Select
III
IV
Jr.
Sr.
Business Name
address 1 required
Address 1
*
Address 2
city required
City
*
State
*
state required
Select
Missouri
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Alaska
Arizona
Arkansas
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Delaware
Florida
Georgia
Hawaii
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Illinois
Indiana
Iowa
Kansas
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Maine
Maryland
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Ohio
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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
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.
E-mail Address
email invalid
Email
email and confirm email do not match
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 number required
-
Acfa Num Ext
Prerequisites
Type Selection
check at least one
I am a current member of a Missouri-based breeder association.
*
Yes
No
Type Selection
check at least one
I have completed at least 20 hours of continuing education.
*
Yes
No
Type Selection
check at least one
I have not had any violations for the past year.
*
Yes
No
Type Selection
check at least one
My biosecurity plan has been reviewed and approved.
*
Yes
No
Type Selection
check at least one
Any dogs or kittens sold into commerce are identified by microchip.
*
Yes
No
Date of Last Inspection.
x
*
Upload
Please attach continuing education credits.
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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 02/05/2025
Confirmation Message
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