Form Tr-Ps-16 - Public Warehouse Keeper License Application
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4TR-PS-16 (Rev 5/17)
Total Amount Due $
For Office Use Only
Public Warehouse Keeper License Application
Chapter 99.02, Wis. Stats.
Approved by _________
PW
Mail check and application to: DATCP
Date _______________
(Wisconsin Dept. of Agriculture, Trade and Consumer Protection
Division of Trade and Consumer Protection
License #
Public Warehouse Keeper)
Date Issued
P O Box 8911
Madison, WI 53708-8911
(608) 224-4933
Expires: June 30, 2018
Personal information you provide may be used for purposes other than that for which it was originally collected. [s. 15.04(1)(m), Wis. Stats]
Check
Individual
Corporation
LLC
LLP
Check
Original
One:
One:
Partnership
Cooperative
Other________________
Amended
Legal Name of Public Warehouse Keeper (Individual, Partnership, Corporate or other):
Renewal
State of formation:
Trade Name (If different from legal name):
Phone:
(
)_______- ____________
Mailing Address:
Fax:
(
)_______- ____________
City:
Zip:
County:
State:
Contact Email:
Contact Name (Type or print ):
First
Last
LIST ALL Corporation or Cooperative Officers, Partners, Trustees, or Managers/Members. (If additional space is needed, please attach a list)
TITLE
NAME
PRIMARY STORAGE LOCATION
(Additional Storage Locations on Back)
Inside
Outside
Street
City
Zip Code
Storage
Storage
Sq. Ft. of Space
Type of
Type of
Kind of Goods Stored
( Y or N)
(Y or No)
Building
Roof
(Codes on Information Sheet)
(Circle applicable code)
AA BB CC DD EE FF HH ZZ
1. License Fee (See fee schedule on information sheet)
$
th
2. Late fee of 20% of license fee if post marked after June 30
. (Applies to renewals only.)
3. Surcharge of $100.00 if operating without a license within 1 year of application. (New applicants only.)
The requirement of paying the surcharge is determined by the department
$
Total License Fees: (add lines 1 THROUGH 3)
$
*** If any lines in the following section are left blank, this application is invalid. ***
The undersigned hereby certifies that this is a true, complete and accurate application for a Public Warehouse Keeper License under section 99.02, Wis. Stats. The
undersigned also certifies that the appropriate security requirement is enclosed ____or the appropriate security requirement is on file with the department ______
(check one)
Signature:
Date:
Type or Print (First Name and Last Name):
Position/Title:
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