The Virginia Department of Agriculture and Consumer Services Forms

SERVICES/FORMS

Animal Health

Animal Custody Record

Animal Custody Record Online Reporting System—User Login

Animal Custody Record Online Reporting System—Public Report Search

Animal Care Complaint Form

Animal Health Laboratory Fee Schedule

Animal Health Laboratory Submission Form

Agricultural Animal Seizure Report

Application for Livestock Dealer Registration

Application for Poultry Dealer Registration

Dangerous Dog Registration Form

Dangerous Dog Renewal Form

Dangerous Dog Secondary Owner Information Form

Virginia Dangerous Dog Registry

Equine Event Report

Equine Event Denied Entry Report

Poultry Service Request Form & Fees

Charitable Gaming

Bingo Managers & Callers

Online Bingo Manager & Bingo Caller Registration System

Bingo Manager Certificate of Registration Application – Form 402 (pdf)

Bingo Manager Certificate of Registration Application – Form 402 (xls)

Bingo Caller Certificate of Registration Application – Form 401 (pdf)

Bingo Caller Certificate of Registration Application – Form 401 (xls)

Bingo Manager Training Material

Bingo Caller Training Material

List of Registered Bingo Caller

List of Registered Bingo Manager

Organization Licensing

Tips for using the interactive Excel Bingo/Raffle Applications

Bingo/Raffle/Texas Hold’em Poker Tournament Application - New Applicant (pdf)

Bingo/Raffle/Texas Hold’em Poker Tournament Application - Renewal Applicant (pdf)

Permit Amendment (pdf)

Gaming Personnel Information Update (pdf)

Report of Game Termination, Revised (pdf)

Landlord & Texas Hold’em Poker Tournament Operator Registering

Landlord Registration Application (pdf)

Operator Registration Application (pdf)

Supplier Licensing

Charitable Gaming Supplier Permit Application – Form 301 (Revised 02/26/18)

Certification of Non-Permit Holder – Form 303 (Revised 07/15/21)

Certification of Non-Charitable Gaming/Gambling – Form 304 (Revised 07/30/13)

Annual Supplier Sales and Transactions Report - Form 302 (Revised 08/01/13) (pdf)

Annual Supplier Sales and Transactions Report - Form 302 (Revised 08/01/13) (xls)

Instructions (Revised 07/30/13)

Supplier Transaction Reporting Format

Manufacturer of Electronic Pull-Tab System Licensing

11 VAC 15-40, Charitable Gaming Regulations.

Currently Registered Manufacturers of Electronic Pull-Tab System

Manufacturer of Electronic Pull-Tab System Permit Application – Form 305 (Revised 10/12)

Manufacturer of Electronic Pull-Tab System Permit Application – Personal Information Form – Form 305-A (Revised 10/12)

Manufacturer of Electronic Pull-Tab System Permit Renewal Application – Form 306 (Revised 10/13)

Manufacturer of Electronic Pull-Tab System Permit Renewal Application – Personal Information Form – Form 306-A (Revised 10/13)

Game Management Forms and Complaints

Form 103 - Bingo Session Reconciliation Summary (Revised 10/24/2022) - Required (pdf)

Form 103 - Bingo Session Reconciliation Summary (Revised 10/24/2022) - Required (xls)

Form 103 - Instructions (Revised 10/24/2022)

Form 104-A - Admission Sales Reconciliation - Paper (Revised 03/23/23) - Required (pdf)

Form 104-A - Admission Sales Reconciliation - Paper (Revised 03/23/23) - Required (xls)

Form 104-A - Instructions (Revised 03/23/23)

Form 104-B - Floor Sales Reconciliation - Paper (Revised 12/19/14) (pdf)

Form 104-B - Floor Sales Reconciliation - Paper (Revised 12/19/14) (xls)

Form 104-B - Instructions (Revised 12/19/14)

Form 104-C - Decision Bingo Reconciliation (Revised 08/14/13) - Required (pdf)

Form 104-C - Decision Bingo Reconciliation (Revised 08/14/13) - Required (xls)

Form 104-C - Instructions (Revised 07/30/13)

Form 104-D - Raffle/Treasure Chest Sales Reconciliation - Bingo Session (Revised 03/23/23) - Required (pdf)

Raffle/Treasure Chest Sales Reconciliation - Bingo Session (Revised 03/23/23) - Required (xls)

Form 105 - Instant Bingo/Seal Cards/Pull-Tabs Reconciliation (10/24/2022) - Required (pdf)

Form 105 - Instant Bingo/Seal Cards/Pull-Tabs Reconciliation (10/24/2022) - Required (xls)

Form 105 - Instructions (Revised 10/24/2022)

Form 105-A - Instant Bingo/Seal Cards/Pull-Tabs Reconciliation Continuation (Revised 08/05/13) - Required (pdf)

Form 105-A - Instant Bingo/Seal Cards/Pull-Tabs Reconciliation Continuation (Revised 08/05/13) - Required (xls)

Form 105-A - Instructions (Revised 08/02/13)

Form 106-A - Storeroom Inventory Issue - Paper (Revised 08/01/13) - Optional (pdf)

Form 106-A - Storeroom Inventory Issue - Paper (Revised 08/01/13) - Optional (xls)

Form 106-A - Instructions (Revised 08/01/13)

Form 106-B - Storeroom Inventory Issue - Instant Bingo/Seal Cards/Pull-Tabs (Revised 08/01/13) - Optional (pdf)

Form 106-B - Instructions (Revised 08/01/13)

Form 107 - List of Bingo Workers Form (Revised 08/01/13) (pdf)

Form 107 - List of Bingo Workers Form (Revised 08/01/13) (xls)

Form 107 - Instructions (Revised 08/01/13)

Form 108 - Prize Receipt Form (Revised 08/01/13) (pdf and xls)

Form 108 - Instructions (Revised 08/01/13)

Form 109-A - Storeroom Inventory - Paper (Revised 08/01/13) - Required (pdf)

Form 109-A - Storeroom Inventory - Paper (Revised 08/01/13) - Required (xls)

Form 109-A - Instructions (Revised 07/30/13)

Form 109-B - Storeroom Inventory Form - Instant Bingo/Seal Cards/Pull-Tabs (Revised 08/01/13) - Required (pdf)

Form 109-B - Storeroom Inventory Form - Instant Bingo/Seal Cards/Pull-Tabs (Revised 08/01/13) - Required (xls)

Form 109-B - Instructions (Revised 08/01/13)

Form 110 – Raffle Sales Reconciliation Form – Stand Alone Raffle (Revised 08/01/13) (pdf)

Form 110 – Raffle Sales Reconciliation Form – Stand Alone Raffle (Revised 02/26/18) (xls)

Form 110 – Instructions (08/01/13)

Form 111 - Instant Bingo/Seal Cards/Pull-Tabs Reconciliation Form (Non-Bingo) (Revised 5/24) (pdf)

Form 111 - Instant Bingo/Seal Cards/Pull-Tabs Reconciliation Form (Non-Bingo) (Revised 5/24) (xls)

Form 111 - Instructions (Revised 08/05/24)

Form 111-A - Instant Bingo/Seal Cards/Pull-Tabs Reconciliation Continuation Form (Non-Bingo) (Revised 5/24) (pdf)

Form 111-A - Instant Bingo/Seal Cards/Pull-Tabs Reconciliation Continuation Form (Non-Bingo) (Revised 5/24) (xls)

Form 111-A - Instructions (Revised 08/05/24)

Form 111-B – Instant Bingo/Seal Cards/Pull-Tabs Reconciliation Continuation Form (Non-Bingo) (Revised 5/24) (pdf)

Form 111-B – Instant Bingo/Seal Cards/Pull-Tabs Reconciliation Continuation Form (Non-Bingo) (Revised 5/24) (xlsx)

Form 111-B - Instructions (Revised 08/05/24)

Form 112 - Destruction of Unused Charitable Gaming Supplies (Revised 03/06/14) (pdf)

Complaint Poster (Revised 11/21/17) (pdf)

Form 114 - King of Clubs/Queen of Hearts/Raffle Sales Reconciliation – Social Quarters (Revised 5/18/23) - Required (xlsx)

Form 114 – King of Clubs/Queen of Hearts/Raffle Sales Reconciliation – Social Quarters (Revised 5/18/23) - Required (pdf)

Form 117 – Texas Hold’em Poker Tournament Reconciliation Summary (Revised 5/24) – Required (pdf)

Form 117 – Texas Hold’em Poker Tournament Reconciliation Summary (Revised 5/24) – Required (xlsx)

Form 117 - Instructions (Revised 08/05/24)

Charitable Solicitation

Virginia Exemption Application for Charitable or Civic Organization: (Form 100)

Registration Statement for a Charitable Organization: (Form 102)

Professional Fundraising Registration: (Form 103)

Professional Solicitor Registration: (Form 104)

Professional Solicitor Bond Template: (Form 105)

Solicitation Notice: (Form 120)

Consent to Solicit: (Form 121

Professional Solicitor’s Final Accounting Report Late Fees: (Form 130)

Schedule A – Accounting For All Ticket Sales, Including Solicitation for Donated Tickets: (Form 131)

Commitment for Receipt of Donated Tickets: (Form 132)

Virginia Solicitation of Contributions Law

Rules Governing the Solicitation of Contributions

Unified Registration Statement: This form may be utilized by charitable organizations soliciting in multiple states.

Charitable Solicitation Complaint Form

Credit Services Business

Credit Services Business Registration Form (OCRP-71

Credit Services Business Bond: Template (OCRP-74)

Credit Services Business Irrevocable Letter of Credit: Template(OCRP-73

Virginia Credit Services Businesses Act

OCRP Regulatory Programs Complaint Form

Extended Service Contract

Extended Service Contract Provider/Obligor Application for Registration (OCRP-61)

Virginia Extended Services Contract Providers Act

OCRP Regulatory Programs Complaint Form

Fantasy Contests

Complaint Form

Form 501 - Fantasy Contest Operator Registration Application

Form 501-A – Personal Information Form

Feed, Fertilizer & Seed

CFA Certification Online Application

Commercial Animal Feed Purchasing Report

Commercial Animal Feed Statement of Agreement

Commercial Animal Feed Tonnage Reporting and Payment Agreements Instructions

Fertilizer Tonnage Reporting System

Fertilizer, Soil Amendment, Horticultual Growing Medium Purchasing Report

Fertilizer, Soil Amendment, Horticultural Growing Medium Statement Of Agreement

Fertilizer, Soil Amendment, Horticultural Growing Medium Tonnage Reporting and Payment Agreements Instructions

Industrial Co-Products Guidance

License Packet for Agricultural Products Dealer

License and Product Registration Packet for Commercial Feed

License and Product Registration Packet for Fertilizer

License and Product Registration Packet for Lime

License and Product Registration Packet for Seed

Turf Fertilizer Reporting Tool

Virginia Fertilizer/Lime Contractor — Applicator Permit

Food

Commercial Kitchen Food Processing Application

Home Food Processing Application

Wild Mushroom Harvester Application

Wild Mushroom Retail Sales Application

Fruit, Vegetable & Peanut Marketing Services

Fruit and Vegetable Programs Request for Inspection, Reinspection or Appeal Inspection

Health Clubs

Health Club Registration Form (OCA-31)

Health Club Bond Template (OCA-34)

Health Club Letter of Credit Template (OCA-33)

Health Club Act

OCRP Regulatory Programs Complaint Form

Home Operations

Home Food Processing Application

Home Service Contracts

Home Service Contract Provider Registration Application (Form 801)

Home Service Contract Provider Bond Form (Form 802)

Home Service Contract Provider Line of Credit Form (Form 803)

OCRP Regulatory Programs Complaint Form

Market News Service

Hay Clearing House Request Form

Market News Publications Request Form

Meat & Poultry Services

Application for Permit of Exemption

Application for Permit of Poultry Exemption

Application/Approval for Voluntary Reimbursable Inspection Service

Membership Campgrounds

Application for the Registration of Membership Camping Operator (OCRP-51)

Membership Campground Letter of Credit Template (OCRP-53)

Membership Camping Operator's Bond Template (OCRP-54)

Virginia Membership Campground Act

OCRP Regulatory Programs Complaint Form

Payment Portal

Pesticide Services

Application for New Pesticide Product Registration

Application for Reciprocal Pesticide Applicator Certificate

Application for Virginia Pesticide Business License

Applicator Change of Information

Business Change of Information

Business License Application Instructions

Certificate of Insurance

Complete Business License Packet

Complete Commercial Pesticide Applicator Packet

Complete Registered Technician Packet

Commercial A Pesticide Applicator Certification Application

Commercial Application Instructions

Commercial B Pesticide Applicator Request for Authorization to Take Pesticide Applicator Examination

Pesticide Registered Technician A Application

Pesticide Registered Technician B Application

Pesticide Disposal Registration Form

Power of Attorney

Private Pesticide Applicator Application and Request for Authorization to Take the Pesticide Applicator Examination

Proof of Additional Category Specific Training for Registered Technicians

Registered Technician Instructions

Request to take the Virginia Pesticide Business License Examination

Responsibilities of Commercial Pesticide Applicators and Registered Technicians in Virginia

Training Manual Order Form

Virginia Pesticide Discontinuance Policy

Plant Industry Services

Permit Application

Virginia Pollinator Beekeeper Form

Virginia Ginseng Management Program

Virginia Plants and Plant Product Inspection Law and Quarantine Requirements

Prepaid Legal Service Plan Sellers

Online Registration Application

Virginia Prepaid Legal Services Plan Act

OCRP Regulatory Programs Complaint Form

Transporters of Waste Kitchen Grease

Online Registration

Promotional

Virginia’s Finest Program Application

Travel Clubs

Application for Registration Travel Clubs (OCA-21)

Travel Club Bond Template(OCA-24)

Irrevocable Letter of Credit Travel Clubs Template (OCA-26)

Travel Club Fidelity Bond Template(OCA 25)

Virginia Travel Club Act

Additional Travel Club Registration Guidelines(OCA-23)

OCRP Regulatory Programs Complaint Form

Weights & Measures

Application for the Registration of Motor Fuels

Application for Weights and Measures Service Agency Certification — Taxi Companies

Application for Weights and Measures Service Agency Certification

Application for Weights and Measures Service Technician Certification

Motor Fuel Price Gouging Complaint Form

Registration Packet for Commission Merchants

Registration Packet for Cotton Handlers

Registration Packet for Service Agency and Service Technician

Virginia Public Weighmaster Law and Application

Weights and Measures Service Agency Change of Information Form

Weights and Measures Service Technician Change of Information Form

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