POINT OF CONTACT The individual filling out this form is considered the point of contact (POC) that we will use to reach out to for any questions.First Name(Required)Last Name(Required)Facility Name(Required)Email(Required) Phone number(Required)State(Required)Select OneAlabamaMarylandOhioOregonPlease Provide Your Premise License Information(Required)Select OneI have my Premise License informationMy location is eligible for an exemptionI am in the process of applying for my Premise LicensePlease Provide Your Premise License Information(Required)Select OneI have my Premise License informationI am in the process of applying for my Premise LicensePremise License Number(Required)Premise License Expiration Date(Required) Month Day Year Please upload a Premise License certificate.(Required)Accepted file types: jpg, png, pdf, tiff, Max. file size: 2 GB.Premise License Exemption Reason(Required)Select OneShip to facility practitioner provides veterinary services on a house call basis and does not maintain a veterinary facilityShip to practitioner provides veterinary services solely to ag animals and does not maintain a veterinary facilityPremise License Exemption Reason(Required)Select OneShip to facility is owned, operated, or controlled by an Ohio-licensed VetPremise License Exemption Reason(Required)Select OneShip to facility is owned and operated by a government agencyShip to facility houses privately owned animals where vet services are routinely provided by mobile vetsShip to facility is a teaching facility as established by AVMA accredited schools of veterinary medicineShip to is a temporary facility established under a declared emergencyApplication pending(Required) I am in the process of applying for my Premise License and acknowledge without a Premise License I cannot purchase prescription products. CommentsThis field is for validation purposes and should be left unchanged. Δ
