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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
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Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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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
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 04/26/2024
Confirmation Message
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