Free 00516.pdf - Indiana

APPLICATION FOR INSPECTION OF MOISTURE TESTING EQUIPMENT
State Form 516 (R6 / 10-08) Approved by State Board of Accounts, 2005

OFFICE USE ONLY
Check number: Initials: Facility number: Transaction number:

Indiana Grain Buyers and Warehouse Licensing Agency 101 West Ohio Street Suite 1200 Indianapolis, Indiana 46204 Phone: (317) 232-1356 Fax: (317) 232-1362

Instructions: 1. Complete one application for each facility location. Form may be filled out online and then printed. 2. Retain copy of this application for your files. 3. FORWARD A SIGNED ORIGINAL to the above address. Name of company:

APPLICATION NUMBER

Amount enclosed with application:

$
Address of company (number, street or R.R., city, state and ZIP code): Telephone number:

Location of facility (number, street or R.R., city, state and ZIP code):

Telephone number:

County facility is located in:

Whitley
Directions to facility location: Name(s) of operator(s):

If there has been a change in the person, firm or corporation LEGALLY responsible for the operation of the company during the last twelve (12) months, give the following information:

Date of change (month/day/year): List grain products purchased, exchanged or sold:

Name of previous owner: Number of devices ($10.00 for each device to be inspected):

Date added (month/day/year):

Number added:

ADDED
If number of devices has been changed during the last twelve (12) months, give date and number of devices. Date deleted (month/day/year): Number deleted:

DELETED

MOISTURE TESTING EQUIPMENT
(Give manufacturer's name, model and serial numbers) Name of Manufacturer Model Number
1. 2. 3. 4. 5. 6. NOTE: If more moisture testing equipment, use a separate sheet.

Serial Number

I, or we, herewith make application for inspection and certification of our moisture testing equipment.
Signature of applicant: Title: Date signed (month/day/year):

E-mail Address: