PACFA Application 2019—V8 Page 1 CDA Office Use Only AG_________________ Register SP / DMV SOS Court Deposit/Process Date:___________ _____________ Accounng Code _____________ Check Number ______________ Check Amount ______________ CC Transacon # Pet Animal Care Facilies Act (PACFA) License Applicaon License Category: Please select the categories that apply to your facility. For two or more categories, the fee will be the cost of the highest priced category plus $50 for each addional category. Aquarium Only $450 Bird Breeder $275 Cat Breeder $400 Small Scale Dog Breeder ( <99 transfers) $450 Large Scale Dog Breeder ( >100 transfers) $550 Pet Animal Rescue ( <100 transfers) $325 Pet Animal Rescue ( >100 transfers) $425 Pet Animal Shelter ( <3000 transfers) $450 Pet Animal Shelter ( >3000 transfers) $600 Pet Animal Sanctuary $450 Pet Boarding and/or Training $500 Pet Handler $225 (Transport pet animals for walks, appointments, and/or to their boarding facility) Pet Transporter $350 (Transporng pet animals to retail, wholesale, rescues and shelters) Reple / Amphibian Breeder $275 Retail / Wholesale of Pet Animals $600 Small Animal Breeder $425 Commercial Pet Animal Facility $450 Pet Grooming Facility $400 Please select only the category that applies to your facility. Facility Owner (You own/lease a physical space & operate a grooming business) Mobile Groomer (Operates and performs grooming services using a vehicle, in home &/or trailer as your facility) Self Wash Facility (A facility whose customers wash their own animals) *Independent Contractor (IC) Pet Groomer $350 IC Pet Groomers have the ability to work up to 3 locaons. Please list your locaons: Name: _______________________ Address: ________________________ Name: _______________________ Address: ________________________ Name: _______________________ Address: ________________________ *PACFA Rule 2.7.1 - IC Groomers are required to nofy PACFA in wring if they drop or add locaons. *Note: Change of your physical home address will require a new applicaon. Before applying to be an IC Pet Groomer you should consult the IRS and Colorado Depart- ment of Labor laws and rules to ensure that you meet all legal requirements of an independent contractor. Business Facility Informaon: ALL informaon is REQUIRED Business Type: Sole Proprietor Registered Business: Corporaon, LLC, Partnership, Non Profits Government or Local Municipality Business Name: (Sole Proprietor: Your legal name needs to be in this field. DO NOT LEAVE BLANK) ______________________________________________________________________________________________________________________________ DBA (Doing Business As): (Name on exterior of building/signage or Trade Name, if none write N/A) ______________________________________________________________________________________________________________________________ Business Physical Address: (IC Groomers: Enter the physical address of your home. DO NOT LEAVE BLANK) ______________________________________________________________________________________________________________________________ Business Contact Informaon: ALL informaon is REQUIRED This informaon is for the person who is legally responsible for the business and will be the main point of contact for the facility. Date of Birth:___________ Legal First Name:____________________ Legal Middle Inial:_____ Legal Last Name:_________________________ Mailing Address: _________________________________________________________________________________________________________ Physical Address (if different than mailing):______________________________________________________________________________________ City:________________________________ State:______ Zip Code:_____________________ County: ____________________________________ Preferred Phone Number:_______________________________ Email Address:______________________________________________________ Alternate Person of Contact for Facility (Full name): ___________________________ Alternate Phone Number: _____________________________ New Applicaon Renewal Business moved locaons Adding category to exisng license AG______________ Change of Ownership Change of Business Contact
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Pet Animal are Facilities Act (PAFA) License …...Pet Animal are Facilities Act (PAFA) License Application License ategory: Please select the categories that apply to your facility.
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PACFA Application 2019—V8 Page 1
CDA Office Use Only
AG_________________ Register
SP / DMV
SOS
Court
Deposit/Process Date:___________
_____________ Accounting Code
_____________ Check Number
______________ Check Amount
______________ CC Transaction #
Pet Animal Care Facilities Act (PACFA) License Application
License Category: Please select the categories that apply to your facility.
For two or more categories, the fee will be the cost of the highest priced category plus $50 for each additional category.
Aquarium Only $450
Bird Breeder $275
Cat Breeder $400
Small Scale Dog Breeder ( <99 transfers) $450
Large Scale Dog Breeder ( >100 transfers) $550
Pet Animal Rescue ( <100 transfers) $325
Pet Animal Rescue ( >100 transfers) $425
Pet Animal Shelter ( <3000 transfers) $450
Pet Animal Shelter ( >3000 transfers) $600
Pet Animal Sanctuary $450
Pet Boarding and/or Training $500
Pet Handler $225 (Transport pet animals for walks, appointments,
and/or to their boarding facility)
Pet Transporter $350 (Transporting pet animals to retail, wholesale,
rescues and shelters)
Reptile / Amphibian Breeder $275
Retail / Wholesale of Pet Animals $600
Small Animal Breeder $425
Commercial Pet Animal Facility $450
Pet Grooming Facility $400
Please select only the category that applies to your facility.
Facility Owner (You own/lease a physical space & operate a
grooming business)
Mobile Groomer (Operates and performs grooming services
using a vehicle, in home &/or trailer as your facility)
Self Wash Facility (A facility whose customers wash their own
animals)
*Independent Contractor (IC) Pet Groomer $350
IC Pet Groomers have the ability to work up to 3 locations. Please list your
Business Contact Information: ALL information is REQUIRED This information is for the person who is legally responsible for the business and will be the main point of contact for the facility.
Date of Birth:___________ Legal First Name:____________________ Legal Middle Initial:_____ Legal Last Name:_________________________
Alternate Person of Contact for Facility (Full name): ___________________________ Alternate Phone Number: _____________________________
New Application
Renewal
Business moved locations
Adding category to existing license AG______________
Change of Ownership
Change of Business Contact
PACFA Application 2019—V8 Page 2
Colorado PACFA License Application
Hours of Operation: It is required to select at least two timeslots (hours) on two different days that you are available.
- If you do not maintain ‘regular business hours’ for the public, you must identify the hours when your business is open for inspection.- IC Pet Groomers: Please enter the hours you work, not the hours of the facility you rent space from.
Business Contact Certification: This section needs to be filled out by the primary business contact, only. All items must be completed.
I certify that I am in compliance with all federal, state and local laws, codes or ordinances pertaining to my business activities . Yes ____ No. If No, please identify any code, ordinance, or law with which you are not in compliance and identify how you intend
I am aware the information provided in this application will be used to perform a background search of public records to include
municipal, county and state court records. ________ (initial)
I am aware it is my responsibility to review and comply with the PACFA Rules & Regulations. _________ (initial)
I understand that PACFA Application/License Fees are non-refundable. If for any reason I do not open or close my business during thelicense year my application/license fee will not be refunded. I also understand that the license is non-transferable between locationsand that if I move to a new location I must reapply and pay a new license fee. _____________ (initial)
Has the applicant or applicant's principals, partners, officers, or agents been charged, fined, sentenced, convicted, or entered a plea ofguilty or no contest under any federal, state or local law pertaining to theft, cruelty, neglect or abuse of animals? _____ Yes _____ NoIf Yes, provide the disposition ____________case number ________________ jurisdiction______________ and name (s) of defendantsinvolved:____________________________________________________________________________________________________Charging and Disposition court documents may be required.
Has the applicant or applicant's principals, partners, officers, or agents had a PACFA or similar license denied, revoked or suspended?____Yes ____ No. If Yes, please provide specifics:
By signing below, I affirm that the statements contained herein are true and accurate to the best of my knowledge. I understand that making a mate-rial misstatement in this application is grounds for disciplinary action against my license, which discipline may include denial of this application forlicensure/renewal.
Signature of Primary Business Contact Date of Application
Payment: Acceptable Payment Forms: Check, Money Order or Credit Card. Please make Checks/Money Orders payable to the Colorado Department of Agriculture.
Sole Proprietor / Out of State Business Contacts: The Citizenship/Immigration Status verification form (page 4) is required. Your identification must be valid and in good standing.
LLC’s and all Corporations (including Non-profit corporations): Include the Summary Sheet from the business listing on the Colorado Secretary of State (SOS) website. Out of state facilities: Need to register as a Foreign Entity with the Colorado SOS. (www.sos.state.co.us/biz)
Government or Local Municipality: Please call our office for required documents (303) 869-9146
Please submit your application to: Email (Preferred):
By signing below, I agree that the credit card above will be charged the full application amount. In addition, I agree to pay an addi-tional non-refundable 2.25% of the total amount due to cover the cost of the credit card transaction and a one-time non-refundable processing fee of $0.75.
If you do not have any of these documents, please contact us at 303.869.9146 for additional options to verify your lawful presence in the US.
CITIZENSHIP/IMMIGRATION STATUS VERIFICATION AFFIDAVIT (v10 Nov 2016)
All state agencies are required to verify the lawful presence in the United States of all individuals and individuals doing business as sole proprietors who apply for certain public benefits including the license, permit or registration for which you are applying. (Colorado Revised Statutes section 24-76.5-103)
STEP 1- CHECK AN OPTION, PROVIDE PERSONAL INFORMATION AND SIGN THE AFFIRMATION.
I swear and affirm under penalty of perjury under the laws of the State of Colorado that the information I have provided on this form is complete and accurate and (CHECK ONE OPTION BELOW):
(A) I am a United States Citizen
(B) I am a permanent resident of the United States
(C) I am lawfully present in the United States pursuant to federal law
AND I understand that this sworn statement is required by law because I have applied for a public benefit that is subject to Colorado Revised Statutes section 24-76.5-103. I understand that this state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I understand that if I am not a United States citizen this law requires the Colorado Department of
Agriculture (“CDA”) to verify my lawful presence in the United States through the federal Department of Homeland Security (“DHS”) Citizenship and Immigration Services (“CIS”) Systematic Alien Verification of Entitlement Program. I hereby authorize DHS/CIS to provide CDA with information related to my immigration status. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute section 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received.
Applicant Signature Signature Date
First Name of Individual/Sole proprietor Last Name of Individual/Sole proprietor Date of Birth