Form B-10 - Registration Application For Commercial Fertilizers To Be Distributed In Bulk Or In Packages Exceeding 12 Pounds - Office Of Indiana State Chemist - Purdue University

IC 15‐16‐2‐31 Commercial Fertilizers Law

Office of Indiana State Chemist and Seed Commissioner

FORM B‐10 (REV 2013)

Purdue University

175 S. University Street

West Lafayette, IN 47907‐2063

Telephone: 765‐494‐1492; Fax: 765‐494‐4331

Registration Application for Commercial Fertilizers to be Distributed in Bulk or in Packages EXCEEDING 12 POUNDS

For year ending June 30, ________

Each grade of each brand must be registered prior to being offered for sale, sold or distributed. Application must be accompanied by a fee of $20.00 for each grade of each brand.

Registrant (Company Name)____________________________________________________ Registrant #________________ Telephone:__________________________________

Address:_____________________________________________________________ City:___________________________ State:__________ Zip Code:_______________________

Signed by:____________________________________________________________________________________ Date:________________________________________________

Title:_________________________________________________________________ E‐mail Address:_______________________________________________________________

(1)

(2)

Item

Brand Name & Grade

Guaranteed Analysis

(expressed as percentage)

Reg. No.

Avail.

Soluble

Total

Phos.

Potash

Nitrogen

)

(1)

(2)

Include pesticide guarantee and EPA registration number in this column when claimed on label.

See other side‐source of secondary nutrients and micronutrients must be given.

FOR OFFICE USE ONLY

CERTIFICATE OF REGISTRATION

(To be completed by Office of Indiana State Chemist)

This certifies that the above brands of commercial fertilizer have been approved for distribution in Indiana beginning with the date of registration and ending June 30, _________.

By:___________________________________________________________________ Date:__________________________________

Check #

Amount

Entered Under

Date Posted