Form 1066 - Application For Registration - Arkansas

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Revised Form 1066
Arkansas
20___-20___ APPLICATION FOR REGISTRATION OF 100% NATURAL ORGANIC FERTILIZERS
Arkansas State Plant Board, P. O. Box 1069, Little Rock, AR 72203
In accordance with Regulation No. 2 of the Arkansas Fertilizer Law (Act 106 of 1951 as amended), you are hereby requested to register for sale or distribution in Arkansas the fertilizer brands listed below.
NOTE: The name of any commercial fertilizer or fertilizer material shall be considered as a distinct and separate brand when differing in any respect other than the grade or common name of a fertilizer material.
All Registrations expire June 30 of each year.
FIRM NAME
PHONE
ADDRESS
CITY
STATE
ZIP
Guaranteed Analysis %
***(Minimums listed)
**
Ca
Mg
S
B
Cl
Co
Cu
Fe
Mn
Mo
Na
Zn
%
% Avail
%
*Complete Brand Name
1.0
0.5
1.0
0
0.1
0.1
0.1
0.1
0.1
0.1
Nitrogen Phos. Acid Potash
Sources
.0005
.0005
*For "Specialty Fertilizer" attach a complete label
**Sources (complete if applicable)
***Minimums (complete if applicable)
Number of Brands x $25.00 = ____________________
1. Ammonium Nitrate
6.
11.
2. Nitrogen Solutions
7.
12.
TOTAL FEE ENCLOSED $ _________________________
3. Urea
8.
13.
4. Triple Superphosphate
9.
14.
Please make checks payable to: Arkansas State Plant Board
5. Muriate of Potash
10.
15.
We hereby certify the above descriptions and attachments are true and correct.
Registration No.
Do not write in this space
Approved for fiscal year ending June 30, 20___
Print Name & Title:
Approved by: Jamey Johnson, Director
Division of Feed & Fertilizer
Signature:
Date:
Signature ______________________________
Date Approved __________________________
Page _____ of _____

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