Form 1019 - Application For Feed Facility License - Arcansas State Plant Board printable pdf download

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_____________

Form 1019 - Application For Feed Facility License - Arcansas State Plant Board

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