Commercial Breeder Boarding Kennel and Dealer License NEBRASKA by mikeholy


									                                          NEBRASKA COMMERCIAL DOG AND CAT                                Date of Pre-inspection:
                                              OPERATOR INSPECTION ACT                                            /        /

                                  COMMERCIAL BREEDER, BOARDING KENNEL,
                                     AND DEALER LICENSE APPLICATION

                                                             NEW LICENSE
 1.   Name(s) of Owner(s) - Mailing and Physical Address:                2.    Indicate owners of the facility IF different than operator
      (PLEASE PRINT)                                                           listed in 1: (PLEASE PRINT)
      Name:_________________________________________                           Name:_____________________________________
      Business name:_________________________________                          Address:___________________________________
      Address:_______________________________________                          City/state/zip:_______________________________
      City/state/zip:___________________________________                       County:____________________________________
      County:________________________________________                          Phone #:___________________________________
      Phone #:_______________________________________                          Social Security #:____________________________

      Cell or Work #: _________________________________

      Social Security #:________________________________                 3.    Attending Veterinarian: _______________________

 4.   Are there multiple premises (sites) for your operation?            5.    Does facility have a USDA license?
                         YES                  NO                                       YES               NO 
                                                                               USDA License #: 47-_______________
      If yes, how many? ___________________________

      Location of premises: ________________________

 6.   Total number of dogs and cats sold, traded, bartered,              7.    Current number of dogs or cats being used for
      brokered, given away, boarded, or leased during previous                 breeding purposes:
      calendar year (January 1st – December 31st):
                                                                               Number of dogs: _____________________________
      Number of dogs: _____________________________
                                                                               Number of cats: _____________________________
      Number of cats: _____________________________

 8.   Facility License Fee:
      Initial license applicants shall pay a start-up fee of $125. Initial license applicants will be issued a license upon completion of
      a qualifying inspection. License renewal fees are due annually. A license to operate as a Commercial Breeder, a license to
      operate as a Dealer, or a license to operate as a Boarding Kennel shall be renewed by filing with the Department, at least 30 days
      prior to April 1 of each year, a renewal application and the annual license fee. Twenty dollars will be charged on all renewal
      applications postmarked after March 31st. Renewal fees will be based on the daily average number of dogs or cats housed during
      the previous annual licensure period [April 1st – March 31st]. Checks or money orders are preferred. Make checks payable to the
      Nebraska Bureau of Animal Industry.

 9.   Type of Entity:      Sole Proprietorship        Partnership     Corporation       Other
                                                       United States Citizenship Attestation
          If your facility is a “Sole Proprietorship” or “Partnership,” you must complete this form. If your facility operates as a
          “Partnership,” all partners must sign and date the form.

                                      Complete this section only if you checked “Sole Proprietorship”

      For the purpose of complying with Neb. Rev. Stat. §§4-108 through 4-114, I attest as follows:

       I am a citizen of the United States.

       I am a qualified alien under the federal Immigration and Nationality Act, my immigration status and alien number are as follows:
                                   , and I agree to provide a copy of my USCIS documentation upon request.

      I hereby attest that my response and the information provided on this form and any related application for public benefits are true,
      complete, and accurate, and I understand that this information may be used to verify my lawful presence in the United States.

      Print Name                                        Signature                                      Date

             I certify that the information I have provided is factual and that information has not been withheld that would affect this application for
             a Dog or Cat Commercial Facility License. I also certify that I have not plead guilty, no contest, or have been convicted of any
             violation of any state or federal law on the disposition or treatment of dogs or cats. I further understand that it is unlawful to operate
             without a valid license issued by the State of Nebraska. Any violation of any provision of the act is a Class I misdemeanor.

             Signature of License Applicant: ______________________________                    Date: _______________________________

             Person or persons authorized to receive official notices and orders from the Nebraska Department of Agriculture:

                                   (Name)                                                   (Address, if different from 1 or 2)

                                      This form is to be completed, accompanied with required fees, and returned to:

                                                           Nebraska Department of Agriculture
                                                               Bureau of Animal Industry
                                                                     P.O. Box 94787
                                                                Lincoln, Nebraska 68509

     12. Please indicate the type(s) of license(s) that apply to your operation. Facility definitions are as follows:

                 COMMERCIAL BREEDER
                 Commercial breeder means any one of the following:
                   •  A person who sells, exchanges, leases, or in any way transfers or offers to sell, exchange, lease, or transfer 31 or more
                      dogs or cats in a 12-month period, beginning on April 1 of each year; or
                   •  A person engaged in the business of breeding dogs or cats who owns or harbors four or more dogs or cats, intended for
                      breeding, in a 12-month period, beginning on April 1 of each year; or
                   •  A person whose dogs or cats produce a total of four or more litters within a 12-month period, beginning on April 1 of
                      each year; or
                   •  A person who knowingly sells, exchanges, or leases dogs or cats for later retail sale or brokered trading.

                 BOARDING KENNEL
                 Boarding kennel means a facility which is primarily used to house or contain dogs or cats owned by persons other than the
                 operator of such facility. The primary function of a boarding kennel is to temporarily harbor dogs or cats when the owner of
                 the dogs or cats is unable to do so, or to provide training, grooming, or other non-veterinary service, for consideration before
                 returning the dogs or cats to the owner. A facility which provides such training, grooming, or other non-veterinary service is
                 not a boarding kennel for the purposes of the Act unless dogs or cats owned by persons other than the operator of such
                 facility are housed at such facility overnight. Veterinary clinics, animal control facilities, and nonprofit animal shelters are not
                 boarding kennels for the purposes of the Act.

                 Dealer means any person who is not a commercial breeder or a pet shop, but is engaged in the business of buying for
                 resale, or selling or exchanging dogs or cats as a principal or agent, or who claims to be so engaged. A person who
                 purchases, sells, exchanges, or leases 30 or fewer dogs or cats in a 12-month period is not a dealer.

                                                      FOR OFFICE USE ONLY
     Application for a New License for Commercial Breeders, Boarding Kennels, and Dealers

     License fee: $                                  Check #: ______________________________                Date:

Rev. 10/10

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