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. 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
EXP.:
XX/XXXX
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:
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
File Type
text/rtf
File Title
According to the paperwork reduction Act of 1995, no persons are required to