RESTRICTED DONATION FROM AARM (COLORADO PACFA APPLICATION).PDF

MA 01 Ike lise Only
COLORADO
2040 PACFA
Department of Agriculture PL 2050 Late FeO
Register 1 SP / DMV 2070 Civil Penalty
inspection & Consumer Serytees Division
Scan 7 SOS Check Number
Pet Animal Care Facilities Act (PACFA) Application Attach 7 Court CC Transaction
ri New Application CI Renewal Process / Dep Date: CC Total
[I Previous Business Moved Locations / Li Adding Category to License
Change in Ownership
License Category: Please select the categories that apply to the facility. The fee will be the cost of the highest priced category plus $50 for
each add tional category.
[2 Aquarium Only $350 Li Pet Grooming $320. Please select which applies to your location
H Bird Breeder $200 (no additional fees). You will only select one of the following:
C Cat Breeder $300 Li Facility Owner: You own or lease a physical space and operate a
grooming business.
Dog Breeder—Large Scale $400 (100 or more transfers)
7 Dog Breeder—Small Scale $350 (99 or less transfers) LJ Mobile Groomer: A facility that operates and performs groom-
ing services at either a customers houses or a set location and
Li Pet Animal Rescue $ 225 (A Foster based program) uses their vehicle and/or trailer as their facility.
Pet Animal Shelter; $350 ( <3000 transfers) Li Self Wash Facility: A facility whose customers wash their own
fl Pet Animal Shelter: $ 400 (>3000 transfers) animals.
Li Pet Animal Sanctuary $350 [J Independent Contractor. All Independent Groomers have the
• Pet Boarding and/or Training $400 ability to work at up to 3 locations. You are required to inform
us in writing if you drop or add locations.
Pet Handler $175 (Transport pet animals for walks,
appointments, and/or to their boarding facility) Please list up to 3 locations
(Include the Name & Address of each facility):
Li Pet Transporter $225 (Transporting pet animals to Retail,
Wholesale, Rescues and Shelters)
L: Reptile / Amphibian Breeder $350
Li Retail/Wholesale of Pet Animals $400
H Small Animal Breeder $350
Business Contact Information - All information is required. This information should be 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: iNA. LegaL Middle Initial: F. Legal Last Name: HAQA-1, rs
Mailing Address (where you receive mail): '.SOC) -
Physical Address (if different than mailing address):
City: '- ‘4‘...NALVIv•Ic State: 1\ v Zip Code: Cs-St:022,k County: OCN p1/4-42-k
Preferred Phone Number; (002_,- -GOV Alternate Phone Number:
Email Address: NIA.A.MAMLA.A - . Cok bV
Business Facility Information - All information is required. This should be the physical location of the business. Independent Pet Groomers
with will enter the physical address of their home.
Type of L sole Proprietor (Complete & Submit Attached Immigration Form)
Business: LI Corporation, LLC, Partnership (Submit Summary of Business Listing with the Colorado Secretary of State)
Government or Local Municipality ( Please call or email our office for required documents)
Business Name (Legal Name): p,a)Acc-61- 1)- vtiv 1/42ri "N,r aak Ca ve_ Ar\ek CO-1Thrk-\(0\
DBA (Doing Business As / Name on Exterior of Building or Signage):
Physical Address: 9---',‘500 Sn
City : V yloev-Nke State: Zip Code: County:
Facility Phone Number: b02- - cSOta 5P./' Alternate Person of Contact for Facility: e-P+A SteAn Bibb
PACFA ApplIcation 2017--v 6 Page I

Pet Animal Care Facilities Act (PACFA) Application — Pg. 2
Hours of Operation - If you do not maintain 'regular business hours' for the public, you must identify the hours when your business is open
for inspection. Pet Groomers —Independent Contractors, please enter the hours you work, not the hours of the facility
Please circle the Monday Tuesday Wednesday Thursday Friday Saturday Sunday
hours that you 8am-5pm Ram-5pm 8am-5pm 8am—Spm 8am-5pm 8am-5pm 8am-5pm
are available. 8am-10am 8am-10am 8am-10am Sam-10am 8am-10am 8am-10am Sam-10am
You must select 10am-12pm 10am-12pm 10am-12pm 10am-12pm 10am-12pm 10am-12pm 10am-12pm
at least two
timeslots on 12pm-2pm 12pm-2pm 12pm-2pm 12pm-2pm 12pm-2pm 12pm-2pm 12pm-2pm
two different 2pm-4pm 2pm-4pm 2pm-4pm 2pm-4pm 2pm-4pm 2pm-4pm 2pm-4pm
days. 4pm-6pm 4pm-6pm 4pm-6pm 4pm-6pm 4pm-6pm 4pm-6pm 4pm-6pm
Applicant Certification - (all items must completed)
• I certify that I am in compliance with all 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 to resolve the matter.
• 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. iNnert. (initial)
• I am aware it is my responsibility to review and comply with the PACFA Rules & Regulations. 0--riN (initial)
• I understand that PACFA Application/License Fees are non-refundable. If for any reason I do not open or close my business during the
license year my application/license fee will not be refunded. I also understand that the license is non-transferable between locations
and that if I move to a new location I must reapply and pay a new license fee. MK\ (initial)
• Has the applicant or applicant's principals, partners, officers, or agents been charged, fined, sentenced, convicted, or eptered a plea of
guilty or no contest under any local, state or federal law pertaining to cruelty, neglect or abuse of animals? Yes V No
If Yes, provide the disposition case number jurisdiction
and the name (s) of the defendants
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 1./ 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 material missta ement in this application is grounds for disciplinary action against my license, which discipline may include
• -ni.1 othi ;-... ic tion or I nsure/renewal.
4k 1 k ..- . - IL L 1_01,57(
wir Signature • f Applicant Date of Application
Required documents in addition to this 2 page application:
Li Payment in the form of Check, Money Order or Credit Card. Please make Checks and Money Orders payable to the Colorado
Department of Agriculture. Payment must be submitted with application and/or renewal, otherwise the documents will be returned to
the applicant.
If you are a Sole Proprietor, you must complete the attached Citizenship / Immigration Status verification form. Your identification must
be valid and in good standing, otherwise the application will be returned to the applicant.
fl LLC's and all Corporations must include the Summary Sheet from your Business listing on the Colorado Secretary of States website
(www.sos.state.co.us/biz)
To submit your application please use one of these two options:
Mail the completed form and documentation to: Scan and email the completed forms and documentation to
Colorado Department of Agriculture— PACFA adrienne.bannister@state.co.us
2331 West 31st Avenue Fax to:
Denver, CO 80211 720-634-0934
PACFA Application 2017 —v 6 Page 2