APHIS 7003A Application for License

Animal Welfare; Retail Pet Stores and Licensing Exemptions

APHIS 7003-A aug 2011 0392.rtf

Business

OMB: 0579-0392

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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)


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


Cats






Marine mammals


Wild/exotic Hoofstock


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


Guinea pigs






Farm animals


Bears


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

$

Hamsters






Wild/exotic canines


Wild/exotic mammals

(Not listed elsewhere)


  1. 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 Typetext/rtf
File TitleAccording to the paperwork reduction Act of 1995, no persons are required to
AuthorGovernment User
Last Modified ByHardy, Kimberly A - APHIS
File Modified2013-09-17
File Created2013-09-17

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