certappl

APPLICATION FOR VOLUNTARY CERTIFICATION OF ANIMAL CONTROL AND

HUMANE SOCIETY OFFICERS

MISSION STATEMENT OF CERIFICATION BOARD: There is hereby created a Board of Certification for AC/HSO in the State of Missouri to certify animal control/humane society officers whose duties in public health require knowledge and skills in environment health science, care and nutrition on animals, regulations on safety, submitting rabies samples, knowledge of techniques of public relations and the laws relating to animal welfare in the State of Missouri and to assure continuing education of members so certified.

Date_____________________

Applicant's Name____________________________________Address_________________________________

City: ______________________________________________State:___________________________________

Employer/Agency: ___________________________________________________________________________

Address:_________________________________________________________State______________________

Supervisor's Name_____________________________________________Phone_________________________

Please list all Animal Control/Humane Society experience, or any other animal care related work completed, include dates:

___________________________________________________________________________________________

CERTIFICATION BYLAWS REQUIRE APPLICANTS HAVE SIX MONTHS EXPERIENCE IN ANIMAL CARE/CONTROL FIELD OR HAVE SUCCESSFULLY COMPLETED NACA LEVEL I AND II.

By signing you are declaring that the information on this page is true to the best of you knowledge and you meet the minimum requirements to take the Certification test. If it is determined that the information you have provided is not true and you did not meet the minimum requirement to take the Certification test your Certification will be Void.

__________________________________ ________________

Signature Date

FOR BOARD USE

Date Rec’d ______________ Required Qualifications? Y / N MACA Membership Fees Paid? Y / N Certification Fee Paid? Y / N New_______ Renewal ________ CEU’s Met? Y / N ( for renewal)

Approved_______Disapproved________Date tested____________Score__________