APHIS 7003A Application for License

OMB Approved 0579-0470, Exp XX/XXXX

OFFICIAL USDA USE ONLY
SEND THE COMPLETED FORM TO:

UNITED STATES DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICES

USDA APHIS ANIMAL CARE
2150 CENTRE AVE.
BUILDING B, 3W11
FORT COLLINS, CO 80526

APPLICATION FOR LICENSE
(TYPE OR PRINT)

LICENSE/CUSTOMER NUMBER

EXPIRATION DATE

DATE RECEIVED

No license shall be issued unless a completed application and appropriate fees are received, and the applicant is in compliance with the standards and
regulations (7 U.S.C. §§ 2132-2143). A license may be denied or license terminated if the applicant has made false or fraudulent statements or provided false or
fraudulent records to USDA (9 C.F.R §§ 2.11 and 2.12).
1. TYPE OF LICENSE:

2. TYPE OF ORGANIZATION:

CLASS A- BREEDER

CLASS B- DEALER

CLASS C- EXHIBITOR

INDIVIDUAL

PARTNERSHIP

CORPORATION

OTHER

3. NAME, MAILING ADDRESS, AND COUNTY (SEE INSTRUCTIONS):

4. ADDRESSES OF ALL LOCATIONS, FACILITIES, PREMISES, OR SITES
(P.O. BOX ADDRESSES ARE NOT ACCEPTABLE):
Same as Block 1

COUNTY:

COUNTY:
CHECK IF ADDITIONAL LOCATIONS ARE LISTED ON SEPARATE SHEET.
CHECK IF YOU WILL BE TRAVELING OVERNIGHT WITH ANIMALS.

5. TELEPHONE NUMBER(S):

6. EMAIL ADDRESS:

7. PREVIOUS USDA LICENSE NUMBER (IF ANY):

8. ACTIVE USDA LICENSE NUMBER IN WHICH YOU HAVE AN INTEREST:

9. VIOLATIONS AND NOLO CONTENDRE (9 C.F.R § 2.1(a)(1)(vii))
Disclose any pleas of nolo contendere (no contest) or finding of a violation of Federal, State, or local laws or regulations pertaining to animal cruelty or the transportation,
ownership, neglect, or welfare of animals.
NONE

YES, EXPLAIN (ATTACH ADDITIONAL INFORMATION OR RECORDS.)

10. IF THE APPLICANT IS A CORPORATION, PARTNERSHIP, OR OTHER BUSINESS ENTITY, LIST THE ENTITY’S OFFICERS AND AGENTS.
CHECK THIS BOX IF ADDITIONAL PERSONS ARE LISTED ON AN ADDITIONAL SHEET.

NAME

TITLE

11. LIST THE ACTUAL OR ANTICIPATED TYPES AND MAXIMUM NUMBER OF ANIMALS OWNED, HELD, MAINTAINED, SOLD, EXHIBITED, OR LEASED AT ANY
ONE TIME DURING THE PERIOD OF LICENSURE (9 CFR §2.1(a)(1)(i)):
ANIMAL TYPE

NUMBER

ANIMAL TYPE

NUMBER

ANIMAL TYPE

NUMBER

DOGS

NONHUMAN PRIMATES (GROUPS 1-4)
§3.80(B)(2)(i)

HIPPOPOTAMUSES

CATS

NONHUMAN PRIMATES (GROUPS 5-6)
§3.80(B)(2)(i)

GIRAFFES

GUINEA PIGS

BEARS

WILD/EXOTIC HOOFSTOCK

HAMSTERS

EXOTIC/WILD FELIDS AND HYBRIDS

MARINE MAMMALS

RABBITS

HYENAS, EXOTIC/WILD CANIDS AND
HYBRIDS

FARM ANIMALS (exclude horses)

ELEPHANTS

OTHER ANIMALS (not listed elsewhere)

RHINOCEROSES

TOTAL ANIMALS

CHECK THIS BOX IF ADDITIONAL PAGES ARE USED TO LIST ANIMALS.

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 certify that I have reviewed the Act, regulations, and standards. To the best of my knowledge and belief, I am in compliance with and agree to continue to
comply with all the regulations and standards in 9 CFR, Subpart A, Parts 1, 2, and 3. I certify that I am and all listed persons are 18 years of age or older.
12. SIGNATURE:

13. PRINT NAME AND TITLE:

14. DATE:

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 0579-0470. 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.

APHIS FORM 7003A
FEB 2020

INSTRUCTIONS FOR LICENSE APPLICATION
(APHIS FORM 7003A & TAX IDENTIFICATION SHEET)
• Please read all instructions before completing the application and Tax ID sheet.
• Contact the USDA APHIS Animal Care office at 970-494-7478 for any questions.
• Corrections and/or clarifications will delay the processing of your application.
• ALL BLOCKS MUST BE COMPLETED; if one does not apply please put “N/A”.
• ONLY send to the USDA APHIS Animal Care office:
1. Application (APHIS FORM 7003A)
2. Tax ID sheet (Green sheet)
• Payments can be made by check, money order, or credit card. Cash is not accepted.
Completing the APHIS Form 7003A License Application:
Block 1:

Check the box that best describes your business activity.
• Class A (breeder) – Sells only animals bred and raised at your facility.
• Class B (broker) – Buys and sells animals or is an operator of an auction.
• Class C (exhibitor) – Exhibits animals to the public.

Block 2:

Check the box that best describes your business.
• Individual – Owner name only listed in Block 3.
• Partnership – Either partner’s name or business name listed in Block 3.
• Corporation or Other – Business name listed in Block 3.

Block 3:

Complete this block with the applicant name mailing address, and county.
• Applicant means the name the license will be under.
If applying as an Individual, put the individual’s name only.
If applying as a Partnership, please either list all partner’s names or the business
name.
If applying as Corporation or Other, list the business name only.
• Mailing Address refers to the address all correspondences will be mailed to.
Cannot be left blank, and can include only one address.
Include the county that the business address is in.

Block 4:

List the addresses of all locations, facilities, premises, or sites where the animals,
equipment, vehicles, and records are or will be located.
• P.O. Boxes cannot be listed in this Block.
• Include the county that the address is located.
• If necessary, use an additional sheet if more than one address.

Block 5:

List the telephone number where the applicant can be reached.

Block 6:

List the email address that is used to send and receive electronic correspondence to
the applicant/licensee.

Block 7:

Complete this block if you had a previous license number.

Block 8:

Complete this block if you have a business interest in another active USDA license.

Block 9:

Disclose if you have any animal violations or have pled no contest to animal incidents.
If yes, describe the incident(s) and attach additional information or records, if
necessary.

Block 10:

Complete this block with all officers authorized to conduct business for the license.
• If applying as an Individual, this block does not need to be completed.
• If applying as a Partnership,
Under owners’ names this block does not need to be completed.
Under the business name list all names authorized to conduct business for this
license.
Owner cannot be used as a title.
• Indicate the person who should be listed as the attention person for receiving mail.
If applying as a Corporation or Other;
List all names authorized to conduct business for this license.
Owner cannot be used as a title.
Indicate the person who should be listed as the attention person for receiving mail.

Block 11:

List the actual or anticipated number of animals for each types of animals in the
businesses inventory.
• For animals listed under Group 5 Nonhuman primates include baboons and nonbrachiating species larger than 33.0 lbs. (15 kg.).
• For animals listed under Group 6 Nonhuman primates include great apes over 55.0
lbs. (25 kg.) and brachiating species.

Block 12-14: Complete these blocks with an authorized person’s signature, name, title, and date the
application is signed.

Privacy Act Notice
Authority: The Animal Welfare Act (AWA), 7 U.S.C. 2131 et seq., and the regulations issued thereunder, 9 CFR parts 1 through 4; and the Horse
Protection Act (HPA), 15 U.S.C. 1821 et seq., and the regulations issued thereunder, 9 CFR parts 11 and 12.
Purpose: This system supports APHIS’ administrative activities and enforcement of the AWA and HPA.
Routine Uses:
In addition to those disclosures generally permitted under 5 U.S.C. 552a (b) of the Privacy Act, records maintained in the system may be disclosed
outside USDA as follows:
(1) APHIS may disclose the name, city, State, license or registration type and/or status, or change of a license or registrant to any person
pursuant to 9 CFR 2.38(c) and 2.127;
(2) APHIS may disclose annual reports submitted to APHIS by licensees and research facilities to any person pursuant to 9 CFR 2.7 and 2.36;
(3) APHIS may disclose inspection reports and other regulatory correspondence issued to licensees and registrants [from the agency] to any
attending veterinarian in order to carry out duties under the AWA pursuant to 9 CFR 2.33 and 2.40;
(4) APHIS may disclose the name, telephone number and other contact information, location, inspection reports, and regulatory and other
correspondence of licensees, registrants, permitees, and applicants for the same, to appropriate Federal, foreign, State, local, Tribal, or other
public authority agencies or officials, in order to carry out duties under the AWA or State, local, Tribal or other public authority on the same
subject pursuant to 7 U.S.C. 2145(b);
(5) APHIS may disclose inspection reports of licensees and registrants, and permit status, to any pet store or other entity that is required under
State, local, Tribal, or other public authority to verify a licensee, registrant, or permitee’s compliance with the AWA;
(6) APHIS may disclose information to the National Academies of Sciences, Engineering, and Medicine, and any other research institution
engaged or approved by the Department, to the extent APHIS deems the disclosure necessary to complete research and/or compile a report
in furtherance of the Department’s mission;
(7) APHIS may disclose final adjudicatory AWA and HPA decisions or orders by an appropriate authority to any person;
(8) APHIS may disclose to any person the name, city, and State or other information to the extent necessary for proper identification of persons
(referred to as “Designated Qualified Persons” or “DQPs”) that are or have been qualified to detect and diagnose a horse that is sore or
otherwise inspect horses for purposes of enforcing the HPA and of horse industry organizations or associations (referred to as “HIOs”) that
have currently or have had in the past DQP programs certified by the USDA;
(9) APHIS may disclose to any regulated horse owner, HIO, and other entities responsible for licensure or required to verify compliance with the
HPA, HPA inspection findings and regulatory and other correspondence issued to persons or entities regulated under the HPA;
(10) APHIS may disclose to any person the name, city, and State or other information to the extent necessary for proper identification of any
person or entity who has been disqualified, suspended, and/or otherwise prohibited from showing or exhibiting any horse, or judging or
managing any horse show, horse exhibition, horse sale, or horse auction under the HPA and the terms of such action;
(11) APHIS may disclose to any person the name, city, and State or other information to the extent necessary for proper identification of any
regulated individual or entity whose license or permit has been suspended, revoked, expired, terminated, or denied under the AWA and the
terms of such action;
(12) APHIS may disclose to appropriate law enforcement agencies, entities, and persons, whether Federal, foreign, State, local, or Tribal, or other
public authority responsible for enforcing, investigating, or prosecuting an alleged violation or a violation of law or charged with enforcing,
implementing, or complying with a statute, rule, regulation, or order issued pursuant thereto, when a record in this system on its face, or in
conjunction with other records, indicates a violation or potential violation of law, whether civil, criminal, or regulatory in nature, and whether
arising by general statute or particular program statute, or by regulation, rule, or court order issued pursuant thereto, if the information
disclosed is relevant to any enforcement, regulatory, investigative, or prosecutive responsibility of the receiving entity;
(13) APHIS may disclose to the Department of Justice when the agency, or any component thereof, or any employee of the agency in his or her
official capacity, or any employee of the agency in his or her individual capacity where the Department of Justice has agreed to represent the
employee, or the United States, in litigation, where the agency determines that litigation is likely to affect the agency or any of its components,
is a party to litigation or has an interest in such litigation, and the use of such records by the Department of Justice is deemed by the agency to
be relevant and necessary to the litigation; provided, however, that in each case, the agency determines that disclosure of the records to the
Department of Justice is a use of the information contained in the records that is compatible with the purpose for which the records were
collected;
(14) APHIS may disclose information in this system of records to a court or adjudicative body in administrative, civil, or criminal proceedings when:
(a) The agency or any component thereof; or (b) any employee of the agency in his or her official capacity; or (c) any employee of the agency
in his or her individual capacity where the agency has agreed to represent the employee; or (d) the United States Government, is a party to
litigation or has an interest in such litigation, and by careful review, the agency determines that the records are to be for a purpose that is
compatible with the purpose for which the agency collected the records;
(15) APHIS may disclose information from this system of records to appropriate agencies, entities, and persons when: (a) USDA suspects or has
confirmed that there has been a breach of the system of records; (b) USDA has determined that as a result of the suspected or confirmed
breach there is a risk of harm to individuals, USDA (including its information systems, programs, and operations), the Federal Government, or
national security; and (c) the disclosure made to such agencies, entities, and persons is reasonably necessary to assist in connection with
USDA’s efforts to respond to the suspected or confirmed compromise and prevent, minimize, or remedy such harm;
(16) APHIS may disclose information from this system of records to another Federal agency or Federal entity, when the USDA determines that
information from this system of records is reasonably necessary to assist the recipient agency or entity in (a) responding to a suspected or
confirmed breach or (b) preventing, minimizing, or remedying the risk of harm to individuals, the recipient agency or entity (including its
information systems, programs, and operations), the Federal Government, or national security, resulting from a suspected or confirmed
breach;
(17) APHIS may disclose information in this system of records to USDA contractors and other parties engaged to assist in administering the
program, analyzing data, developing information management systems, processing Freedom of Information Act requests, and conducting
audits. Such contractors and other parties will be bound by the nondisclosure provisions of the Privacy Act;
(18) APHIS may disclose information in this system of records to USDA contractors, partner agency employees or contractors, or private industry
employed to identify patterns, trends, or anomalies indicative of fraud, waste, or abuse;
(19) APHIS may disclose information in this system of records to a Congressional office from the record of an individual in response to any inquiry
from that Congressional office made at the written request of the individual to whom the record pertains;
(20) APHIS may disclose information in this system of records to the National Archives and Records Administration or to the General Services
Administration for records management activities conducted under 44 U.S.C. 2904 and 2906; and
(21) APHIS may disclose information in this system of records to the Treasury Department as necessary to carry out any and all functions within
their jurisdiction, including but not limited to, processing payments, fees, collections, penalties, and offsets.
Disclosure: Furnishing this information is voluntary; however, failure to furnish this information may impede your ability to comply with the requirements
of the Animal Welfare Act, regulations, and standards.