New Jersey Department of Health

Infectious and Zoonotic Diseases Program

APPLICATION FOR CERTIFICATION AS AN

ANIMAL CONTROL OFFICER

In order to be certified, an applicant must have satisfactorily completed a training course approved by the New Jersey Department of Health.

Name of Applicant - First	Middle	Last

Date of Birth

Street Address

Daytime Telephone Number

City	State	Zip Code

Evening Telephone Number

E-mail Address

Education - Highest Grade Completed

School Where Animal Control Officer Course Was Completed

Course Grade

Date Course Completed

Have you ever been convicted of, or found civilly liable, for a violation of any provision of Title 4, Chapter 22, of the Revised Statutes, otherwise known as the “Animal Cruelty Laws?”	Yes No	STATE USE ONLY
Approved: Yes No

Date: _________________

Cert. No.: ______________
Signature of Applicant	Date
VPH-32

JUL 12

VPH-32, Application for Animal Control Officer Certification

VPH-32, Application for Animal Control Officer Certification, IZDP, ACO, animal control, animal control officer

EWhite

2001-05-25

NJDOH