Maryland Poultry Registration Form - Department Of Agriculture

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Maryland Poultry
REGISTRATION FORM
Registration is MANDATORY by authority of:
Agric. Art., Section § 3-804.
Annotated Code of Maryland
#_________________________
(Please print all information)
Poultry Caretaker’s Name: ___________________________________________________________
First
Middle
Last
Phone: (
) - _____________ Cell: (
) - ______________ E-mail: ____________________
Mailing Address: ____________________________________________________________________
Physical Address:
): _____________________________________________________
(If PO Box is used
City _____________________ State: _____ Zip: ________ - ______County:___________________
Number of locations to register: ______ (
Please register each location separately)
Address of kept birds:
:_________________________________________
(If different than prior address)
City: _____________________ State: _____Zip: ________ - _____ County:___________________
Domestic Poultry:
(Check ALL that apply, include the number of birds maintained during the last 12 months)
Chickens #_________
Game Birds (chucker’s, pheasants, quails) #________
Ratites (ostriches, emus) #_________
Turkeys # _________
Waterfowl (ducks, geese, swans) #_______
Pigeons or Doves: # ________
A pond is located on the
A body of water is located near this property
Exotic Birds: (Registration of Exotic Birds is voluntary)
__________________ #______
___________________#______ _______________#______
(Check ALL that apply)
Purpose of flock:
Auction
Contracted
Hobby/Pet
Live bird Slaughter/Market
Own Consumption
Show/Competition
Other: _______________
What were the sources for the birds
Auction
Commercial
Mail Order
Neighbor
Retail
Self-Raised
Other:
_________________
National Poultry Improvement Program certified?
No
Yes #__________
I would like to register this property in the National Animal Identification System (NAIS).
Completed by: _________________________________ (signature) Date: _________________
Questions: 410-841-5810 (phone), 410-841-5999 (fax),
animalhealth@mda.state.md.us
(e-mail)
Return form to: MD Dept. of Agriculture Poultry Registration,
50 Harry S. Truman Pkwy, Annapolis, MD 21401
MDA E-14 (Rev. 2/10)

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