Form AH-025 Riding Stable/Pet Shop/Animal Shelter Application - Michigan

Form AH-025 is a Michigan Department of Agriculture and Rural Development form also known as the "Riding Stable/pet Shop/animal Shelter Application". The latest edition of the form was released in February 1, 2014 and is available for digital filing.

Download an up-to-date Form AH-025 in PDF-format down below or look it up on the Michigan Department of Agriculture and Rural Development Forms website.

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AH-025 (Rev: 2/14)
Michigan Department of Agriculture and Rural Development
P.O. Box 30776, Lansing, MI 48909-8276 ~ 517-284-5769
In accordance with 1974 PA 93, and 1969 PA 287, as amended.
Riding Stable/Pet Shop/Animal Shelter Application:
License Year Ending: ______
License No Longer Needed.
If Renewal, License No. of Establishment(s):______________________________
Business Information:
Business Name: ______________________________________________________
Business Address: ____________________________________________________
City: ______________________________________ State: ___________________
Business Phone: (_____)______________ Business Fax: (_____)_______________
Business Email: ______________________________________________________
Mailing Address (If Different From Above): _______________________________
City: ______________________________________ State: __________________
BLANK SPACE INTENTIONALLY
County: ___________________________________ Zip: ___________________
LEFT FOR OFFICE USE ONLY.
Corporate/Owner Information:
(An assumed name certificate must accompany this application if applicable)
Other: Specify _____________
Ownership Type:
Corporation
Sole Ownership
Partnership
L.L.C.
C
orporation Name: _________________________________________________________________________________________
Owner/President (CEO) Name: ________________________________________________________________________________
Street Address of Corporation or Owner: ______________________________________________________________
City: ___________________________________ State: __________ County: ___________________ Zip: _________
Phone: (_____)_______________ Fax: (_____)_____________ Email: _______________________________________
Emergency Contact: (_____)______________ Cell Phone: (_____)________________
Federal/Tax ID #:
License Fees:
(Please Indicate ALL that Apply)
ANIMAL SHELTER
PET SHOP
RIDING STABLES
Payment Method:
Animal Protection Shelter*
New: $200
New: $100
Check/Money Order No.
Animal Control Shelter**
Renewal: $100
Renewal: $50
_______________________________
~ NO FEE ~
AOBJ: 0109
AOBJ: 0216
Amount Enclosed: $____________
Please make ckeck/money order payable to: The State Of Michigan. Submit Payments to the address at top of form.
I hearby certify that the statements given above are true and correct to the best of my knowledge. I agree to comply with the provisions of
1974 PA 93, to operate a Riding Stable and/or 1969 PA 287, to operate a Pet Shop or Animal Shelter, and Department of Agriculture regulations
made pursuant thereto, and to make such records available to the Director of Agriculture, or a Department Representative, on demand.
Signature: _______________________________________________ Date: ______________________
Please Print your name here: ___________________________________________________________
Title: _______________________________________________________________________________
* Application must be signed by the President of the Animal Welfare Society
** Application must be signed by the Chairman of the Board of Commissioners, City Manager, or Mayor
Veterinarian Information:
www.michigan.gov/mda-licensing
Hospital Name: ___________________________________________________________________________________
Veterinarian Name(s): _____________________________________________________________________________
Hospital Address: _________________________________________________________________________________
City: __________________________________ State: ______ County: ___________________ Zip: ______________
Business Phone: (_____)__________________
AH-025 (Rev: 2/14)
Michigan Department of Agriculture and Rural Development
P.O. Box 30776, Lansing, MI 48909-8276 ~ 517-284-5769
In accordance with 1974 PA 93, and 1969 PA 287, as amended.
Riding Stable/Pet Shop/Animal Shelter Application:
License Year Ending: ______
License No Longer Needed.
If Renewal, License No. of Establishment(s):______________________________
Business Information:
Business Name: ______________________________________________________
Business Address: ____________________________________________________
City: ______________________________________ State: ___________________
Business Phone: (_____)______________ Business Fax: (_____)_______________
Business Email: ______________________________________________________
Mailing Address (If Different From Above): _______________________________
City: ______________________________________ State: __________________
BLANK SPACE INTENTIONALLY
County: ___________________________________ Zip: ___________________
LEFT FOR OFFICE USE ONLY.
Corporate/Owner Information:
(An assumed name certificate must accompany this application if applicable)
Other: Specify _____________
Ownership Type:
Corporation
Sole Ownership
Partnership
L.L.C.
C
orporation Name: _________________________________________________________________________________________
Owner/President (CEO) Name: ________________________________________________________________________________
Street Address of Corporation or Owner: ______________________________________________________________
City: ___________________________________ State: __________ County: ___________________ Zip: _________
Phone: (_____)_______________ Fax: (_____)_____________ Email: _______________________________________
Emergency Contact: (_____)______________ Cell Phone: (_____)________________
Federal/Tax ID #:
License Fees:
(Please Indicate ALL that Apply)
ANIMAL SHELTER
PET SHOP
RIDING STABLES
Payment Method:
Animal Protection Shelter*
New: $200
New: $100
Check/Money Order No.
Animal Control Shelter**
Renewal: $100
Renewal: $50
_______________________________
~ NO FEE ~
AOBJ: 0109
AOBJ: 0216
Amount Enclosed: $____________
Please make ckeck/money order payable to: The State Of Michigan. Submit Payments to the address at top of form.
I hearby certify that the statements given above are true and correct to the best of my knowledge. I agree to comply with the provisions of
1974 PA 93, to operate a Riding Stable and/or 1969 PA 287, to operate a Pet Shop or Animal Shelter, and Department of Agriculture regulations
made pursuant thereto, and to make such records available to the Director of Agriculture, or a Department Representative, on demand.
Signature: _______________________________________________ Date: ______________________
Please Print your name here: ___________________________________________________________
Title: _______________________________________________________________________________
* Application must be signed by the President of the Animal Welfare Society
** Application must be signed by the Chairman of the Board of Commissioners, City Manager, or Mayor
Veterinarian Information:
www.michigan.gov/mda-licensing
Hospital Name: ___________________________________________________________________________________
Veterinarian Name(s): _____________________________________________________________________________
Hospital Address: _________________________________________________________________________________
City: __________________________________ State: ______ County: ___________________ Zip: ______________
Business Phone: (_____)__________________

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