Premises Registration Form
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2North Carolina Department of Agriculture & Consumer Services
NCDA&CS Veterinary Division: Premises Registration Form – Website
Swine
Swine
Swine
Swine
Premises Owner Account Information:
Check:
ID Tags
Tattoo
Ear Notch Number
Business/Farm Name
: ______________________________________________________________________________________
Primary Contact:
_____________________________ _____________________________ _____________________________
(First Name)
(Middle Name)
(Last Name)
Secondary Contact
:_____________________________ ____________________________ ____________________________
(Optional)
(First Name)
(Middle Name)
(Last Name)
Mailing Address:
__________________________________________________________________________________________
City:
State
Zip
County
____________________________
: ______
: ________________-_________
: ______________________
Phone Number
: _________-_________-_____________ ext: ________
Business
Home
Cell
Fax
Pager
Phone Number
: _________-_________-_____________ ext: ________
Business
Home
Cell
Fax
Pager
Email:
(*For notification purposes only)
Business Type
:
Individual
Partnership
Incorporated
LLC
LLP
Government Entity
Non-profit Organization
Premises Information:
(Primary location where livestock reside-if animals are managed on separate locations, apply for multiple premises ID’s.)
Premises Type:
Production Unit / Farm / Ranch
Market / Collection Point
Exhibition
Clinic
Laboratory
Non-Producer Participant
Slaughter Plant
Other: ___________________
(ie: DHIA, non-animal prem., etc.)
Premises Name:
(example: heifer place, farm #1, headquarters)
Address Information: Check box if same as mailing address
(Do not check if mailing address is a PO Box or Route and Box Number)
Premises Address: _____________________________________________________________________________________________
(If different from mailing)
City:
____________________________
State:
______
Zip:
________________-_________
County:
______________________
N _______
°___________
W________°____________
GPS Coordinates at entrance: Latitude
Longitude
(*optional and if known)
Species Information:
** PLEASE FILL IN QUANTITY (how many animals do you have) per species**
(Check all that apply. Quantities of animals are only reported to the state database. This information is protected by General Statute 106-24.1. This and all
other statutes can be viewed at Please see reverse side for more information.)
Cattle
:
Beef
Dairy
Bison Qty
: ______
Goats
:
Meat
Dairy
Fiber Qty
: ______
Sheep
:
Meat
Dairy
Fiber Qty
: _____
Equine
Horse
Donkey
Mule
Camelids
Alpaca
Llama
Cervids
:
Qty: __________
:
Qty: ________
: Qty: ________
Aquaculture: _______________________________
Other Species: __________________________ Qty: _______________
Poultry:
Chicken
Turkey
Ratite
(ostrich and/or emu) Qty: __________
Waterfowl/Game bird
Other
Qty: _________
(If you grow poultry on contract for a corporation, please indicate production system and corporation for which you grow.)
Poultry Production System
:
Broilers
Layers
Breeders
Commercial Toms
Commercial Hens
Integrator/Corporation
: _____________________________________________
Swine:
Breeding
Feeding
Nursery Qty: ______________
Other Qty: _____________
(If you grow swine on contract for a corporation, please indicate production system and corporation for which you grow.)
Swine Production System
:
Sow
Nursery
Finisher
Sow-Nursery
Sow-Finisher
Isolation Unit
AI/Boar Stud
Integrator/Corporation
: _____________________________________________
Producer/Contact Signature:
Date:
(*required)
*If you need assistance or have questions, please contact the NCFarmID office. (See reverse side for contact information)*
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