APHIS 7003A Application for License

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0579-0036 and 0579-0392. The time required to complete this information collection is estimated to average .25 hours per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.

OMB APPROVED 0579-0036 and 0579-0392

No license may be issued unless a completed application has been received (7 U.S.C. 2132-2143), and the applicant is in compliance with the standards and regulations Section 2133.

DO NOT USE THIS SPACE - OFFICIAL USE ONLY

UNITED STATES DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE APPLICATION FOR LICENSE (TYPE OR PRINT) NEW license

SEND THE COMPLETED FORM TO:

USDA-APHIS-Animal Care 2150 Centre Avenue, Building B Mail Stop # 3W11 Fort Collins, CO 80526-8117

LICENSE/customer number

Expiration DATE

AMOUNT

DATE RECEIVED

1. NAME OF applicant AND MAILING ADDRESS: (See Instructions) COUNTY: TELEPHONE NUMBER:

2. ALL BUSINESS NAMES AND LOCATION ADDRESSES HOUSING ANIMALS: Include directions to each location (P.O. Box not acceptable) Use additional sheet, if necessary COUNTY: TELEPHONE NUMBER:

3. IF the applicant is a corporation, partnership or other business entity, List the entity’s partners or officers and agent for service of process.

4. (A) previous usda license number: (If any) (B) ACTIVE usda license number in wHICH you have an interest:

Name

Title

5. TYPE OF LICENSE: Class A – Breeder Class B – Dealer Class C – Exhibitor

6. List your 12 month BUSINESS YEAR: (Calendar or Fiscal)

7. TYPE OF ORGANIZATION: Individual Corporation Partnership Other __________________________________________________________

FROM

TO

MO

DAY

YEAR

MO

DAY

YEAR

8. DEALERS ONLY - class a or class b licenses must complete this block. (Class C Licenses go to Block 9)

9. EXHIBITORS ONLY - List the largest number of animals that you have held, owned, leased, or exhibited at any one time during the previous business year. (9 CFR Sections 2.6 and 2.7)

Class A (Breeder) – Line “D” = ½ of Line “C” Class B (Dealer) – Line “D” = Line C Less the Purchase cost of the AnimalS Sold. (9 cfr Sections 2.6 and 2.7)

Dogs

Nonhuman primates

Rodents (Do not include lab rats or mice)

Estimate total Number of animals to be purchased in the next business year

Cats

Marine mammals

Wild/exotic Hoofstock

Estimate total Number of animals to be sold in the next business year

Guinea pigs

Farm animals

Bears

Estimate Gross Dollar amount derived from Regulated activities (sales, commissions, etc.)

$

Hamsters

Wild/exotic canines

Wild/exotic mammals (Not listed elsewhere)

Estimate Dollar Amount on which fee is based

$

rabbits

Wild/exotic felines

Total (All animals listed in Block 9)

CERTIFICATION I hereby make application for a license under the Animal Welfare Act 7 U.S.C. 2131 et seq. I certify that the information provided herein is true and correct to the best of my knowledge. I hereby acknowledge receipt of and agree to comply with all the regulations and standards in 9 CFR, Subpart A, Parts 1, 2, and 3. I certify that the applicant is 18 years of age or older.

10. SIGNATURE:

11. PRINT NAME AND TITLE:

12. DATE:

APHIS FORM 7003A (Previous editions are obsolete)

AUG 2011