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2. Facility Specific Information <br /> Check one <br /> KC Animal Care and Control ❑ Humane Society <br /> Background Questions Yes No <br /> 1. Have any applicants, partners, or managers had a suspension, revocation, or restriction <br /> of a professional license? 1X1 <br /> If yes, list and explain on a separate sheet of paper. <br /> 2. Have any applicants, partners, or managers been found guilty of a drug or controlled <br /> substance violation? ❑ In <br /> If yes, list and explain on a separate sheet of paper. <br /> 3. Contact Information <br /> Contact Person Name Phone (enter 10 digit#) Email Address <br /> Glynis Frederiksen 425-257-6013 gfrederiksen@everettwa.gov <br /> Title <br /> Animal Services Manager <br /> Veterinarian(s) License Number Date of Employment <br /> Bethany Zolikoff, DVM VT00006059 October 8, 2017 <br /> 4. Additional Information <br /> Legal Owner Information—attach additional sheets as needed <br /> List names, addresses, phone numbers, and titles of corporate officers, partners, members, managers, etc. <br /> Name Address Phone (enter 10 digit#) Title <br /> Change of Ownership Information <br /> Previous Name of Legal Owner <br /> N/A <br /> Previous Name of Facility Previous License# Effective Date of Ownership Change <br /> Physical Address <br /> DOH 672-069 October 2014 Page 2 of 3 <br />