Application For Bonded Weighmasters License (Business) Form Page 2
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2What 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
made? ? Yes ? No If yes, state details ________________________________________________________
The undersigned applicant hereby certifies and affirms that (1.) all statements, oaths, information and schedules attached hereto
are hereby made a part of this application and that all statements, oaths, information and schedules contained herein are true and
correct; (2.) applicant has executed an official weighmasters oath; (3.) all employees retained to perform public weighing must be a
citizen of the United States or a person who has declared his intention of becoming such a citizen, who is a resident of the State of
Mississippi, not less than twenty-one (21) years of age, of good moral character, who has the ability to weigh accurately and to make
correct weight certificates; (4.) a bond in the penal sum of five thousand dollars ($5,000.) payable to the State of Mississippi with
sureties to be approved by the Secretary of State of the State of Mississippi for the faithful performance of the duties of a public
weighmaster is supplied with this application; (5.) an impression seal or electronic impression of the weighers name and license
number as required by Section 75-27-311 of the code will be used by each public weigher employed by applicant; and (6.) compliance
with all requirements of the Bonded Weighmasters Law and Regulations adopted thereunder will be strictly observed.
This the __________ day of ____________________, __________.
______________________________________
Full name of applicant
______________________________________
Firm name
__________________________________________
By
__________________________________________
Title
NOTE: (1.) Application must be signed. If partnership, each partner must sign. If corporation, corporate name must be
signed in full with the officer’s name or name of agent authorized to sign the application and title. (2.) Corporate seal must be
impressed.
State of ______________________________________
County of ____________________________________
This day personally came and appeared before me, the undersigned authority in and for the jurisdiction aforesaid,
_________________________________________ who, being by me first duly sworn, states on oath that the matters and things in the
foregoing instruments are true and correct as herein stated.
______________________________________
Affiant
Sworn to and subscribed before me on this the ______________ day of ____________________________, _________ .
_______________________________________
Notary Public
My commission expires__________________________
NOTE: THE FOLLOWING MUST BE ATTACHED AND MADE A PART OF THIS APPLICATION:
1. $5,000 surety bond payable to the State of Mississippi (Surety must be approved by the Secretary of State)
2.
Weighmaster’s Oath (signed by applicant)
3.
Statement that weighing device(s) has been tested and declared to be accurate, within tolerance allowed by NIST
handbook 44 for such device, by state weights and measures jurisdiction
4. Check or money order in the amount of $100.00 payable to the Mississippi Department of Agriculture and
Commerce
Office Use Only
Do Not Write Below
(Date Received)
Check Number ________________________
Amount Received ______________________
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