Free 18496.FH11 - Indiana

APPLICATION FOR LIVESTOCK DEALER LICENSE
State Form 18496 (R6 / 2-09) INSTRUCTIONS:

Return to: INDIANA STATE BOARD OF ANIMAL HEALTH 805 Beachway Drive, Suite 50 Indianapolis, Indiana 46224-7785

Use ink or type all information. Every dealer is required to be licensed under this act as required by Indiana Code 15-17-1 and shall keep such records, accounts and memoranda as shall fully and correctly disclose all purchases, sales or transfers involving livestock transactions consummated in connection with his business. Date of birth (if an individual) (month, day, year) Telephone number

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Name of person, firm or corporation Address where business will be conducted (number and street, city, state and ZIP code) Name of contact person within the organization (if different than above) Principal address of contact person (if different than above) (number and street, city, state, and ZIP code) Nature of business enterprise Business status of firm

(

)

County of address where business will be conducted

Stockyards

Packer

Individual dealer Auction market

Have you ever been convicted of having committed a felony?

Individual Limited Liability Company Yes

No

Are you registered and bonded with USDA-P&SA?

where business will be Partnership Corporation Is the areazoned for such business? conducted Yes No Limited Liability Partnership

Packer buying station Concentration point

Order buyer

New application Renewal
If a new application or a change of ownership, send a copy of approval / contract from government agency that granted zoning approval / contract for location of business.

Amount paid for livestock purchased in Indiana during previous calendar year.

$

Are you / your agents now under any suspension or other disciplinary order issued by the Secretary of Agriculture of the U.S. pursuant to the Packers and Stock Yards Act (7 U.S.C.) Yes No Amount received for consigned livestock sold on Are scales maintained in Indiana and utilized in weighing of commission during previous livestock purchased or sold in Indiana? calendar year Yes $ No

Yes

No

Number of head purchased during the previous calendar year at this facility, or number of head purchased covered by this license. Hogs Cattle Horses/Mules Sheep/Goats Deer Llama Ostrich/Emu All Other Buffalo

Hogs

Cattle

Number of head of consigned livestock sold on commission during previous calendar year. Horses/Mules Sheep/Goats Deer Llama Ostrich/Emu Buffalo

All Other

If business is to be transacted by a manager, supervisor or resident agent other than the corporate officer as shown above, indicate full name, title and complete address.
1. Name Home Address (number and street, city, state and ZIP code) Title Date of birth (month, day, year)

List full names and complete addresses of all persons who will act as agents or representatives in the actual buying or selling (attach separate sheet if necessary).
1. Name Home Address (number and street, city, state and ZIP code) 2. Name Home Address (number and street, city, state and ZIP code) 3. Name Home Address (number and street, city, state and ZIP code) Date of birth (month, day, year) Date of birth (month, day, year) Date of birth (month, day, year)

NOTARY CERTIFICATE STATE OF COUNTY OF SS:

The undersigned, being duly sworn upon his oath, states or affirms that he is the applicant (or duly authorized representative of the applicant herein named, to make this affidavit) and that he has read the foregoing statements and that to the best of his knowledge and belief they are true and correct and that he will comply with all laws and regulations of the Board of Animal Health pertaining to his business.
Signature of applicant Signature of applicant's representative Date subscribed and sworn To (Notary Public) Date signed (month, day, year) Signature of Notary Public Date signed (month, day, year) Printed or typed name of Notary Public County of residence Date commission expires (month, day, year)