STATE OF MISSISSIPPI
Department of Agriculture and Commerce
Lester Spell, Jr., D.V.M., Commissioner
WEIGHTS AND MEASURES DIVISION
P.O. Box 1609
Jackson, MS 39215-1609
No. ________________
APPLICATION FOR BONDED WEIGHMASTERS LICENSE
(INDVIDUAL)
The undersigned hereby applies for a license to engage in business as a Bonded Weighmaster, as defined by Section 75-27-303(3)
Mississippi Code of 1972, as amended, such license being required by Section 75-27-307(1) for any individual who engages in
business as a public Weighmaster or by Section 75-27-307(a-d) for individuals not required but permitted to hold such license for the
performance of the duties of a Bonded Weighmaster.
Full Name of Applicant
Applicants Mailing Address
Age
Date of Birth
Company Represented
Company Physical Address
City
State
Zip Code
Telephone Number
Company Mailing Address
City
State
Zip Code
Fax Number
County
Date Employed
Present Position
? Yes
? No
Is Applicant a resident of the State of Mississippi?
? Yes
? No
Is Applicant a citizen of the United States?
If not, has applicant declared
? Yes
? No
intention to become a citizen of the United States?
Does Applicant understand correct weight procedures and how to complete correct weight certificates?
?
? No
Yes
What is the primary property, commodity, produce or article to be weighed or measured by applicant
____________________________.
Type of Scale (weighing device):
a. Name __________________________________
b. Serial No. ______________________________
c. Capacity ________________________________
d. Date of last official test ____________________
Has Applicant ever held a license or authorization to perform similar duties to those for which this application is
? Yes
? No If yes, state details ___________________________________________________
made?
(Continued of Back)