Pulpwood Receiving Facility License Application Form
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1
2No. ___________________
Mississippi Department of Agriculture and Commerce
P.O. Box 1609
Jackson, Mississippi 39215-1609
PULPWOOD RECEIVING FACILITY
LICENSE APPLICATION
The undersigned hereby applies for a license to operate a pulpwood receiving facility as defined in section 3(e) of the Uniform
Pulpwood Scaling and Practices Act, such license being required by Section 5(l) of said act.
Name of Pulpwood Yard
Name of Owner
Physical Address of Pulpwood Yard (No PO Boxes)
City
State
Zip Code
Pulpwood Yard Telephone No.
County
Mailing Address
City
State
Zip Code
Office Telephone No.
Fax
County
Number of cords purchased during previous twelve months
? Stick Scaling
? Weighing
Method of measurement:
Type of Scale (weighing device):
Date Last Official
Name
Serial #
Capacity
Test
? Individual
? Partnership
? Corporation
? Cooperative
This business is owned by a (an)
If Corporation, what state incorporated __________________________ Date: _______________
Principal office in the State of Mississippi ___________________________________________
If Corporation list all officers:
Title
Name
Address
President
Vice President
Secretary
Treasurer
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