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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The North Carolina Department of Agriculture & Consumer Services (Information Technology Services) form is 4 pages long and contains:

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  • 27 check-boxes
  • 52 other fields

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Page 1 of 4
modified 4 January 2020
North Carolina Department of Agriculture & Consumer Services
Animal Welfare Section/Veterinary Division
License Application / Renewal Application to Operate as the Following:
Name of Facility
Physical Address
City
NC
ZIP Code
County
Mailing Address
City
NC
ZIP
C
ode
Mailing Address (if different from physical address)
Phone Number
F
ax Number
Email
Owner Information
Name of Owner
Owner's Address
City
ZIP Code
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 License
Renew a License
Facility License #
Print Form
# of Dog Enclosures
# of Cat Enclosures
Time of 1st
Cleaning
Time of 2nd
Cleaning
H
ours Open to the Public
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.
Email
Phone Number
Pet Shop Selling Dogs or Cats ($75 fee)
Public Auction ($75 fee)
Only USPS
1030 Mail Service Center
Raleigh, NC 27699
Only FedEx/UPS
2 W. Edenton St.
Raleigh, NC 27601
phone: 919.707.3280 fax: 919.733.6431 email: agr.aws@ncagr.gov
Mailing Application
click to sign
signature
click to edit
Name of Facility
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. [02
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 veterinary care on 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.
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 twic
e daily
(includi
ng weekends
an
d holidays)
?
YES
NO
Descri
be 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 remain current with rabies
vaccinations? YES NO
List any other vaccinations that you require for dogs and cats:
Page 2 of 4
modified 4 January 2020
Owner/Manager Initials _________________
Veterinarian’s Initials _________________
Name of Veterinary Practice
Name of Veterinarian
Address
City
3. 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 1 year after the release of the animal. [02 NCAC 52J .0103]
4. Does your facility retain or plan to retain (new facilities) all animal records for at least 1 year after the release of an animal?
YES NO
5. 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 or injured during their stay at the facility. Does your facility
have a designated area for the isolation of animals that are sick or injured during their stay?[02 NCAC 52J .029(5)]
YES NO
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
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) then please disregard this question (5(d)).
Page 3 of 4
modified 4 January 2020
Briefly describe your procedure for the isolation of incoming ill or injured animals as well as animals that become ill
or injured during their stay at the facility:
6. Detail your protocol(s) for providing emergency veterinary care including emergency care during and after normal
hours of operation. [02 NCAC 52J .0210(a)]
7. I certify that the facility named above has implemented this Program of Veterinary Care and that the veterinarian
__
__
__
__________________________________
Signature
of
Owner or Authorized Agent (required)
________________________________________
Signature
of
V
eterinarian
(required)
_______________
__
__
__
__
______
Date
______________
_______________
Date
Page 4 of 4
modified 4 January 2020
8. 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
the result of or exacerbated by this failure.
9. As owner or authorized agent, I affirm that all information included in this application is a true and accurate
10. As owner or authorized agent, I agree to comply with the N.C. Animal Welfare Act and the regulations 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.
Owner/ Authorized Agent Initials
11. 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.
NOTICE
A license 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 need to apply for renewal in June.
Owner/Authorized Agent Initials
Owner/Authorized Agent Initials
named above assisted in its development.
Owner/Authorized Agent Initi
als
12. 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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