Certification For Renewal Of Pulpwood Receiving Facility License Form
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1No. ___________________
Mississippi Department of Agriculture and Commerce
P.O. Box 1609
Jackson, Mississippi 39215-1609
CERTIFICATION FOR RENEWAL OF PULPWOOD RECEIVING
FACILITY LICENSE
Name of Pulpwood Yard
Name of Owner
Physical Address of Pulpwood Yard (No PO Boxes)
City
State
Zip Code
Pulpwood Yard Telephone No.
County
Mailing Address
City
State
Zip Code
Office Telephone No.
Fax
County
Certification: This is to certify that the above information is true and correct and that
none of the information shown on the original license application for the above named
pulpwood yard has changed.
________________________________________ ____________________________________
Authorized Signature
Date
NOTE:
Please fill out the above information and return to this office along with the
license fee of $30.00 payable to the Mississippi Department of Agriculture
and Commerce.
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