Fillable North Carolina Department of Agriculture & Consumer Services (Information Technology Services)

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North Carolina Department of Agriculture & Consumer Services (Information Technology Services)

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  • 31 check-boxes
  • 53 other fields

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Page 1 of 5
modified 4 January 2020
North Carolina Department of Agriculture & Consumer Services
Animal Welfare Section/Veterinary Division
Registration Application / Renewal Application to Operate as the Following:
Name of Facility
Physical Address
City
NC
ZIP Code
County
Mailing Address
City
NC
ZIP
Code
Mailing
A
ddress (if different from physical address)
Phone Number
F
ax Number
Email
Owner Information
Name of Owner
O
wner's A
ddress
C
ity
ZIP
C
ode
State
Information About the Facility
Monday Tuesday Wednesday
SaturdayFriday
Thursday
Sunday
Days Open to the Public (check all that apply):
Maximum # Dogs On-Site
Maximum # Cats On-Site
Signature of Owner or Authorized Agent Date
Check one
New Registration
Renew a Registration
Facility License #
Print Form
# of Dog Enclosures
# of Cat Enclosures
Time of 1st
Cleaning
Time of 2nd
Cleaning
H
ours Open to the Public
Animal Shelter (no fee for registration)
Cleaning Hours: (cleanings required at least twice daily).
If more than twice daily, please indicate additional cleaning
times in the comment box of section 1 on the next page.
Phone Number
Email
Only USPS
1030 Mail Service Center
Raleigh, NC 27699
Only FedEx/UPS
2 W. Edenton St.
Raleigh, NC 27601
Mailing Applications
Phone: 919.707.3280 Fax: 919.733.6431 E-mail: agr.aws@ncagr.gov
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signature
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Phone Number
NC
ZIP Code
Veterinarian's NC License #
Veterinarian's Information
Annual Program of Veterinary Care
PURPOSE: This form is to be used for documenting the program of veterinary care in facilities licensed/certified under the Animal Welfare Act.
[NCAC 52J.0210] A written Program of Veterinary Care to include disease control and prevention, vaccination, euthanasia, and adequate
veterinary care shall be established with the assistance of a licensed veterinarian. (This veterinarian is not necessarily the one providing the
veterinary care for the animals). If space is inadequate, use the back of this page or attach additional page(s). This form must be signed by the
owner or manager of the facility and the veterinarian.
Name of Facility
Facility License #
1. Enclosures and exercise areas for dogs and cats must be properly cleaned a minimum of two times per day.
[
02 NCAC 52J .0207(a)]
Is your facility cleaned a minimum of twice daily (including weekends and holidays)? YES NO
Describe your
procedures
for
disinfecti
ng the following:
p
rimar
y enclosures,
ex
ercise areas,
feed &
water
bowls
, l
itter
boxes
and beddi
ng (if
provided)
.
2. All animals in a licensed or registered facility must be in compliance with the North Carolina rabies law,
NCGS § 130A, Article 6, Part 6. [02 NCAC 52J.0210(d)]
Does your facility ensure that all dogs and cats 4 months of age and older, that have been in your facility
for 15 days or more, have been vaccinated for rabies? YES NO
List any other vaccinations that you require for dogs and cats:
Page 2 of 5
modified 4 January 2020
Owner/Manager Initials _________________
Veterinarian’s Initials _________________
Name of Veterinary Practice
Name of Veterinarian
Address
City
 A complete record of veterinary care is required. [02 NCAC 52J .0101(1-5)]
Veterinary care of all animals must be fully documented from the time of intake to the time of release from the facility.
All animal records must be retained a minimum of 3 years after the release of the animal. [NCGS 19A-32.1(j)]
Does your facility retain or plan to retain (new facilities) all animal records for at least 3 years after the release of an
animal?YES NO
 All facilities must designate an isolation area for animals being treated or observed for communicable diseases.
This applies to incoming animals as well animals that become ill during their stay at the facility. [02 NCAC 52J .029(5)]
Does your facility have a designated area for the isolation of animals?
YES NO
Briefly describe your procedure for the isolation of incoming ill animals as well as animals that become ill during their
stay at the facility:
Owner/Manager Initials __________________
Veterinarian’s Initials _________________
5. Diseased or deformed animals shall be sold or adopted only under the policy set forth in the "Program of Veterinary
Care." Full written disclosure of the medical condition of the animal shall be provided to the new owner. [02 NCAC
52J .0210(c)]
a. Does your facility sell, adopt or transfer dogs and/or cats? YES NO
b. Does your facility sell, adopt or transfer any deformed (i.e. blind, amputee, etc.) dogs and/or cats?
YES NO
c. Does your facility sell, adopt or transfer any ill dogs and/or cats? YES NO
d. If you answered YES to questions 5(b) or 5(c), please detail the protocol for the sale or adoption of diseased
Page 3 of 5
modified 4 January 2020
and/or deformed animals, including any health guarantees or refunds as well as the procedure for
providing a full written disclosure.
If you answered NO to both 5(b) and 5(c), please disregard this question 5(d).
7. Detail your protocol(s) for providing emergency veterinary care, including emergency care during and after normal
hours
of operation. [02
NCAC 5
2J .0210(a)]
10. I certify that the facility named above has implemented this Program of Veterinary Care and that the veterinarian
Page 4 of 5
modified 4 January 2020
6. Sick, diseased, injured, lame or blind dogs or cats shall be provided with veterinary care or be euthanized, provided
that this shall not affect compliance with any state or local law requiring the holding, for a specified period, of
animals suspected of being diseased. [02 NCAC 52J .0210(c)]
Does the facility provide veterinary care for the animals in the facility that are ill or injured (i.e. animals not ill
or injured to the degree that would necessitate euthanasia)?YES NO
Detail the facility’s protocol(s) for providing adequate veterinary care:
8. Does this facility provide veterinary surgical services on site? YES
NO
9. Does your facility perform euthanasia?
YES
NO
named above assisted in its development.
Owner/Authorized Agent Initials
11. Does your facility have an emergency disaster plan?
NO
YES
If no, please be advised that AWS will consider your failure to have and/or implement an emergency disaster
plan as an aggravating factor in evaluating any violation that may occur during an emergency/disaster that is
a result of or exacerbated by this failure.
12. As owner or authorized agent, I affirm that all information included in this application is a true and accurate
13. As owner or authorized agent, I agree to comply with the N.C. Animal Welfare Act and the regulations issued pursuant
representation of policies, procedures and actual practices of this faciilty.
thereto. I agree to cooperate as required by law with inspections and investigations conducted by personnel of
the Animal Welfare Section, Veterinary Division, of the N.C. Department of Agriculture & Consumer Services.
14. The person signing this application represents and warrants that they have full authority and representative
capacity to execute this application in the capacities indicated herein, and that this agreement constitutes
the valid and binding obligations of all parties.
Owner/Authorized Agent Initials
Owner/Authorized Agent Initials
Owner/Authorized Agent Initials
NOTICE
A registration is not transferable. "When there is a transfer of ownership, management or operation of a
business…(they) shall have 10 days from such sale or transfer to secure license…A licensee shall promptly notify
the director of any change in the name, address, management or substantial control of their business or
operations." [NCGS 19A-31]. (Forms for these changes may be found on our website www.ncaws.com under AWS
Forms)
If applying for a license/registration before March 31st, you will still need to apply for renewal in June.
__________________________________________
Signature of Owner or Authorized Agent (required)
________________________________________
Signature of Veterinarian (required)(req
_____________________________
Date
_____________________________
Date
Page 5 of 5
modified 4 January 2020
15. I will notify the Animal Welfare Section should there be any significant changes to the practices and information contained in this
application.
Owner/Authorized Agent Initials
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Completed 20 July 2020

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