2. Attachment A- APPLICATION- Required with Submisson.pdf

PDF 197 KB Posted

Attached to
FY26 MDAR Departmental RFR- MA Animal Fund- Qualified Veterinarian List for Spay/Neuter Voucher Prgm
Solicitation number
BD-26-1002-1003-001-121108
Issued by
Suffolk County, Massachusetts

About this file

Written by GovTribe AI ·

This document is an application cover sheet for the Mass Animal Fund Veterinarian Voucher Program for Fiscal Year 2026, issued by MDAR (Massachusetts Department of Agricultural Resources). The form is designed for veterinarians and veterinary practices to apply to become qualified contractors for the state's animal fund voucher program. The application requires detailed contractor information, including legal name, address, contact details, and a list of up to five veterinarians with their corresponding license numbers.

The application form is structured to capture comprehensive information about potential veterinary service providers, with a specific requirement that all legal contractor names must match their associated Tax ID numbers. The document appears to be part of a standardized qualification process for veterinarians to participate in a state-sponsored animal healthcare voucher program, updated in September 2025. The form allows for alternate business names and contact information, providing flexibility for veterinary practices with multiple locations or business structures.

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AGR-MA-Vet-Voucher-Program-FY26

Updated: September-2025

Qualified Contractor List- Mass Animal Fund Veterinarians

APPLICATION COVER SHEET

Required with Submission

Date:

CONTRACTOR INFORMATION:

Legal Name:

Contractor, Business or Municipality:*

Legal Address City, Town, Zip Main Phone: Email:

Contact Name:

Contact Phone: Email:

*Note: All legal contractor names must match Tax ID numbers associated with the legal name being referenced

If different from above:

Do Business As d/b/a:

Address:

City, Town, Zip Contact Name:

Contact Phone: Email:

Alt Phone: Alt Email:

Veterinarian Name & License Number:

# NAME LICENSE NUMBER

1.

2.

3.

4.

5.

Date:
Legal Name Contractor Business or Municipality:
Legal Address:
City Town Zip:
Main Phone:
Email:
Contact Name:
Contact Phone:
Email_2:
Do Business As dba:
Address:
City Town Zip_2:
Contact Name_2:
Contact Phone_2:
Email_3:
Alt Phone:
Alt Email:
NAME1:
LICENSE NUMBER1:
NAME2:
LICENSE NUMBER2:
NAME3:
LICENSE NUMBER3:
NAME4:
LICENSE NUMBER4:
NAME5:
LICENSE NUMBER5:

File details come from the government source that posted it. Updated .