Fsi-463-15 - Application For Food Salvager License - Nys Department Of Agriculture And Markets
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1
2FSI-463-15 (03/15)
APPLICATION FOR FOOD SALVAGER LICENSE
NYS Department of Agriculture and Markets - Article 17-B
(Office Use Only)
County Code - Est. No:
Entity No. ________________________
Receipt No._______________________
Certificate No._____________________
INSTRUCTIONS
APPLICATION MUST BE FULLY COMPLETED
An original signature of owner or corporate officer is
required in Section (7).
Completion and submission of this form does not
constitute authorization to operate as a Food Salvager.
(1) Individual Owner Name, Partnership or Full Name of the Corporation:
County:
Trade Name:
Business Telephone Number:
(
)
Street:
City:
State:
Zip:
E-Mail:
Bank Name:
(2) Optional Mailing Address:
Street:
City:
State:
Zip:
(3) Identification Number:
Federal ID Number
OR
Social Security Number
(4) Please list sole proprietors and all officers of a corporation or cooperative. If applicant is a partnership, LLC, or LLP, list partners/members
(attach list if necessary). If applicant is a non-public corporation, list shareholders (attach list if necessary).
Title
Work Address (Street & No., City, State, Zip)
Date of
Name (Please Print)
E-Mail address
Birth
(4a.) Principal Office Address: ______________________________________________________________________________________________
(4b.) In what state incorporated? ________________________ (4c.) Date of Incorporation _____________________________________________
(4d.) Are you a foreign or out of state individual, partnership, or corporation? (Check One)
Yes
No
(4e.) For foreign or out-of-state corporations:
Date of filing in New York State? ____________________
(4f.) If out-of-state, the applicant agrees to accept service of process by first class mail to the designated individual at the said address below which shall
constitute good and proper service of process.
Designated:_____________________________________
Address: _______________________________________________________
(PLEASE COMPLETE REVERSE SIDE)
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