"Request to Designate a New Agency Onsite Manager" - Kentucky

Request to Designate a New Agency Onsite Manager is a legal document that was released by the Kentucky Board of Veterinary Examiners - a government authority operating within Kentucky.

Form Details:

  • Released on March 1, 2020;
  • The latest edition currently provided by the Kentucky Board of Veterinary Examiners;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Kentucky Board of Veterinary Examiners.

ADVERTISEMENT
ADVERTISEMENT

Download "Request to Designate a New Agency Onsite Manager" - Kentucky

410 times
Rate (4.8 / 5) 25 votes
K
B
V
E
ENTUCKY
OARD OF
ETERINARY
XAMINERS
107 Corporate Drive, Second Floor, Frankfort, KY 40601
Office: 502-782-0273  Fax: 502-695-5887
kybve.com
vet@ky.gov
OFFICIAL USE ONLY
Request to Designate a New Agency Onsite Manager
Instructions: This request form must be completed by the animal control agency
who must report a new designated onsite manager or to update the contact information
for the designated onsite manager in accordance with 201 KAR 16:572. Completion of
all fields on this application is mandatory. Insufficient answers or omissions will be
sufficient grounds for rejection of this request. Review the check list on the last
page to ensure your request is complete. Print SINGLE SIDED; DO NOT staple.
I.
Agency Contact Information
Name of Animal Control Agency
Agency Website
Agency Phone Number
Agency Email Address
Address Type
Street
City
Zip
County
Mailing Address
Physical Address #1
Physical Address #2
Fiscal Agent of Agency
Fiscal Agent
Address
Fiscal Agent Phone Number
Fiscal Agent Email Address
Submit Complete Application to:
Kentucky Board of Veterinary Examiners
Page 1 of 2
107 Corporate Dr, Second Floor
Form Last Updated: 03/2020
Frankfort, Kentucky 40601
K
B
V
E
ENTUCKY
OARD OF
ETERINARY
XAMINERS
107 Corporate Drive, Second Floor, Frankfort, KY 40601
Office: 502-782-0273  Fax: 502-695-5887
kybve.com
vet@ky.gov
OFFICIAL USE ONLY
Request to Designate a New Agency Onsite Manager
Instructions: This request form must be completed by the animal control agency
who must report a new designated onsite manager or to update the contact information
for the designated onsite manager in accordance with 201 KAR 16:572. Completion of
all fields on this application is mandatory. Insufficient answers or omissions will be
sufficient grounds for rejection of this request. Review the check list on the last
page to ensure your request is complete. Print SINGLE SIDED; DO NOT staple.
I.
Agency Contact Information
Name of Animal Control Agency
Agency Website
Agency Phone Number
Agency Email Address
Address Type
Street
City
Zip
County
Mailing Address
Physical Address #1
Physical Address #2
Fiscal Agent of Agency
Fiscal Agent
Address
Fiscal Agent Phone Number
Fiscal Agent Email Address
Submit Complete Application to:
Kentucky Board of Veterinary Examiners
Page 1 of 2
107 Corporate Dr, Second Floor
Form Last Updated: 03/2020
Frankfort, Kentucky 40601
Kentucky Board of Veterinary Examiners
Request to Designate a New Agency Onsite Manager
II.
Agency Designated Onsite Manager
First Name
Middle Name
Last Name
Date of Birth
Social Security Number
(required)
(required)
Address Type
Street
City
ST
Zip
County
Personal Mailing
Address
Business Phone
Cell Phone
Personal Email Address
Business Email Address
1. Are you now, or have you ever been, addicted to or undergone treatment for the use of narcotics, drugs,
prescription drugs, or the excessive use of intoxicating substances, including alcohol?
☐ Yes or ☐ No If yes, explain. Attach supporting documents if necessary.
________________________________________________________________________________
2. Have you ever been convicted of a felony or misdemeanor other than a minor traffic violation?
☐ Yes or ☐ No If yes, explain. Attach supporting documents if necessary.
________________________________________________________________________________
III. Application Check List
☐ Inspection agreement. Acknowledgment of agreement to submit to inspection by a Board
representative pursuant to 201 KAR 16:550.
☐ Background Check. Complete and submit the official results of a background check to KBVE for the
agency designated onsite manager from a Board approved provider. Visit
www.kybve.com
on the Forms
page and look under the Background Checks heading for more information.
Date Requested: ______________
☐ Disciplinary records. If applicable, complete copies of any and all records of actions or circumstances
listed in Section II, Question 1. If no disciplinary records to disclose, check the box: ☐ N/A
I hereby state that the information contained herein is true and accurate to the best of my knowledge, and
that should the Kentucky Board of Veterinary Examiners determine that any statement herein is false, I
understand that the Board may suspend, revoke, or terminate any certificate issued by the Board.
Further, I understand that the animal control facility and all animal euthanasia specialist employees under
the facility’s direct supervision, if any, are required to abide by KRS Chapter 231 and 201 KAR Chapter 16.
For direct links to the laws and regulations which shall govern the agency’s euthanasia activities, I am aware
I can visit the Board’s website at
www.kybve.com
to download the materials.
_____________________________________
___________________
Signature of Agency Designated Onsite Manager
Date
Submit Complete Application to:
Kentucky Board of Veterinary Examiners
Page 2 of 2
107 Corporate Dr, Second Floor
Form Last Updated: 03/2020
Frankfort, Kentucky 40601
Page of 2