Form 1019
(10-99)
APPLICATION FOR FEED FACILITY LICENSE
Under The
ARKANSAS FEED LAW AND REGULATIONS
For Calendar Year ending December 31, 20______
Instructions:
Complete the sections below and submit to the Arkansas State Plant Board,
P. O. Box 1069, Little Rock, AR 72203.
A separate application is required for each location.
Feed Facility License:
Any person or firm who manufactures a commercial feed within this state; or who distributes a
commercial feed in or into the state or whose name appears on the label of a commercial feed as guarantor, shall obtain a license
for each facility which distributes in or into the state authorizing him to manufacture or distribute commercial feed before he engages
in such activity. Licenses must be renewed by January 15 of each year. Any new applicant who fails to obtain a license within fifteen
(15) working days after notification of the requirement to obtain a license or any licensee who fails to comply with license renewal
requirements shall pay a thirty dollar ($30.00) late fee in addition to the license fee. Facility licenses expire December 31 of each
year.
Feed Facility License Fee $10.00 ................Late Fee ( if any)____________ AMOUNT ENCLOSED $_______________
I hereby certify that I will observe the current Feed Law and Regulations. I understand that failure to comply with such regulations
could result in cancellation of my facility license.
Firm Name _________________________________________Phone___________________________________________
Mailing Address ____________________________________________________________________________________
City & State ____________________________________________________________Zip_________________________
Physical Address ____________________________________________________________________________________
City & State ________________________________________________________________Zip_____________________
E-mail:___________________________________________________________________________________
Check the appropriate box:
NEW FACILITY LOCATION / COMPANY
RENEWAL- LICENSE #_____________(Required for current registrants)
Corporate Office
Pays Tonnage for others (list in separate paper with the corresponding License #)
=
Pays Tonnage? (If you don
t pay your tonnage, please fill out who pays it.)
Who pays for tonnage?___________________________________________________________________________
This company manufactures what type of feed? CHECK ALL THAT APPLIES:
Livestock
Pet Food
Bird Feed
Mineral & Vitamins
FOR OFFICE USE ONLY
Others_____________________________________
Approved for calendar year ending December 31, 20_____.
Approved by Jamey Johnson, Director
Division of Feed & Fertilizer
Printed Name of Registering Official:
________________________________________________
Signature______________________________________
_______________________________________________
License ______________
Date:___________________
Signature
Title____________________________Date_____________