2019 Out-Of-State Distributor License - Kansas

This fillable "Out-Of-State Distributor License" is a document issued by the Kansas Department of Agriculture specifically for Kansas residents.

Download the PDF by clicking the link below and complete it directly in your browser or through the Adobe Desktop application.

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2018-2019 Out-of-State Distributor License
$650
Renewal Application
*A current USDA license is Required*
New Application
* = required field
Apply online at:
https://www.kellysolutions.com/ks/indexAnimalHealth2.asp
State License #: ________________
USDA License #: _________________
Premise County: _________________
Address and Contact Information
Check which phone number you prefer:
*Owner/Operator Name: _______________________________
*Home Phone: ______________________________
*Applicant Mailing Address: ___________________________
Cell Phone: ________________________________
*City ___________________________ *Zip: ______________
Work Phone: _______________________________
*Premise/Business Name: ______________________________
*Email: ____________________________________________
*Premises Physical Address: ____________________________
(NOT PO BOX)
*City ___________________________ *Zip: ______________
FEIN #: _________________________________________________
License Details
*Please initial. See the Kansas Pet Animal Act at:
agriculture.ks.gov/afi
______ As an out-of-state distributor, I agree that this premise complies with K.S.A 47-1701(bb)
Y / N *Have you or any of your employees ever been convicted of any crime relating to theft or cruelty to animals?
(if yes, a letter of explanation MUST be attached)
*How many dogs/cats will you buy for resale in Kansas between October 1 and September 30? Dogs: _________ Cats: _________
*A list of breeders you plan to buy from must be attached. Please include the breeders name and address.
*Vet care forms expire a year from the date your veterinarian signs it. Licenses will not be renewed unless a current form is on file.
Current veterinary care form is on file with the AFI Program
I have attached a current veterinary care form
Hours & Designated Representative
Inspections are routinely conducted Monday through Friday, 7 am to 7 pm. pursuant to K.A.R. 9-18-9(c). Inspectors will
attempt to accommodate your preferred hours of inspection; however, we cannot guarantee they will arrive during your
preferred hours that are listed on your application. If you are not routinely available for an inspection Monday through
Friday from 7 am to 7 pm, a designated representative is required to be on file. Please note, a no contact fee of $200 will be
assessed if your premise is not made available for an inspection within 30 minutes upon the inspector arriving on your
premises.
*What are your preferred hours for inspection? ___________________________________________________________________
**Designated Representative(s) other than owner): ________________________________________________________________
**Required per K.A.R. 9-18-2 (d)
Designated Representative phone(s): ___________________________________________________________________________
*Directions to Premise: ________________________________________________________________________________________
I understand that Kansas law permits that a licensee may have routine inspections and may be inspected upon complaint. I consent to
the inspections by the Kansas Department of Agriculture. I understand inspections may be conducted outside of my preferred hours
Monday to Friday, 7am to 7pm. As a licensed USDA premises, I understand and agree that by signing this form my medical records,
reflecting adequate veterinary care treatment of the animals in my custody fall under the USDA guidelines. I understand that a willful
disregard of any provision of the Kansas Pet Animal Act or of any regulations adopted there under may subject the licensee to
suspension or revocation of the license and/or fine of up to $1000 per violation and/or criminal penalties. I understand that a material
misstatement in this application form may be grounds for denial, suspension or revocation of a license. The information contained
within this application is true and correct to the best of my knowledge. All RENEWAL applications not postmarked by 11-15-2018
will be assessed a $70.00 late fee.
Owner Signature: _______________________________________________
Date: ______________________________________
Printed Name: __________________________________________________
TO BE COMPLETED BY KDA STAFF ONLY
OAD: _________________________
AHL: _________________________
Transaction #: _________________________
CC/CK#: ___________________________
2018-2019 Out-of-State Distributor License
$650
Renewal Application
*A current USDA license is Required*
New Application
* = required field
Apply online at:
https://www.kellysolutions.com/ks/indexAnimalHealth2.asp
State License #: ________________
USDA License #: _________________
Premise County: _________________
Address and Contact Information
Check which phone number you prefer:
*Owner/Operator Name: _______________________________
*Home Phone: ______________________________
*Applicant Mailing Address: ___________________________
Cell Phone: ________________________________
*City ___________________________ *Zip: ______________
Work Phone: _______________________________
*Premise/Business Name: ______________________________
*Email: ____________________________________________
*Premises Physical Address: ____________________________
(NOT PO BOX)
*City ___________________________ *Zip: ______________
FEIN #: _________________________________________________
License Details
*Please initial. See the Kansas Pet Animal Act at:
agriculture.ks.gov/afi
______ As an out-of-state distributor, I agree that this premise complies with K.S.A 47-1701(bb)
Y / N *Have you or any of your employees ever been convicted of any crime relating to theft or cruelty to animals?
(if yes, a letter of explanation MUST be attached)
*How many dogs/cats will you buy for resale in Kansas between October 1 and September 30? Dogs: _________ Cats: _________
*A list of breeders you plan to buy from must be attached. Please include the breeders name and address.
*Vet care forms expire a year from the date your veterinarian signs it. Licenses will not be renewed unless a current form is on file.
Current veterinary care form is on file with the AFI Program
I have attached a current veterinary care form
Hours & Designated Representative
Inspections are routinely conducted Monday through Friday, 7 am to 7 pm. pursuant to K.A.R. 9-18-9(c). Inspectors will
attempt to accommodate your preferred hours of inspection; however, we cannot guarantee they will arrive during your
preferred hours that are listed on your application. If you are not routinely available for an inspection Monday through
Friday from 7 am to 7 pm, a designated representative is required to be on file. Please note, a no contact fee of $200 will be
assessed if your premise is not made available for an inspection within 30 minutes upon the inspector arriving on your
premises.
*What are your preferred hours for inspection? ___________________________________________________________________
**Designated Representative(s) other than owner): ________________________________________________________________
**Required per K.A.R. 9-18-2 (d)
Designated Representative phone(s): ___________________________________________________________________________
*Directions to Premise: ________________________________________________________________________________________
I understand that Kansas law permits that a licensee may have routine inspections and may be inspected upon complaint. I consent to
the inspections by the Kansas Department of Agriculture. I understand inspections may be conducted outside of my preferred hours
Monday to Friday, 7am to 7pm. As a licensed USDA premises, I understand and agree that by signing this form my medical records,
reflecting adequate veterinary care treatment of the animals in my custody fall under the USDA guidelines. I understand that a willful
disregard of any provision of the Kansas Pet Animal Act or of any regulations adopted there under may subject the licensee to
suspension or revocation of the license and/or fine of up to $1000 per violation and/or criminal penalties. I understand that a material
misstatement in this application form may be grounds for denial, suspension or revocation of a license. The information contained
within this application is true and correct to the best of my knowledge. All RENEWAL applications not postmarked by 11-15-2018
will be assessed a $70.00 late fee.
Owner Signature: _______________________________________________
Date: ______________________________________
Printed Name: __________________________________________________
TO BE COMPLETED BY KDA STAFF ONLY
OAD: _________________________
AHL: _________________________
Transaction #: _________________________
CC/CK#: ___________________________

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