State Form 550 - Application For Livestock Brand Registration

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APPLICATION FOR LIVESTOCK BRAND REGISTRATION

INDIANA STATE BOARD OF ANIMAL HEALTH

State Form 550 (R / 5-96)

805 Beachway Drive, Suite 50

Approved by State Board of Accounts 1996

Indianapolis, Indiana 46224-7785

Name of business / farm (if applicable)

Name of individual

Name as it should appear on the certificate:

Address of business / farm (street, city, state, ZIP code)

County

Telephone number

County

Telephone number

Mailing address (if different)

Amount enclosed (see instructions)

New application

Check number

Renewal (if a renewal, skip to signature)

NOTE: BRANDS ARE NOT RECORDABLE ON THE HEAD OR NECK AREA OF LIVESTOCK OR ON THE RIBS OF HORSES. (See instructions)

(RIGHT SIDE)

(LEFT SIDE)

EARS

(LEFT SIDE)

(RIGHT SIDE)

(LEFT SIDE)

Draw your first choice on livestock above and on the attached sketch form, and write the name of the brand as you read it here:

SECOND CHOICE:

Draw your second choice in the space above and write the name of the brand as you read it here:

NOTARY CERTIFICATE

STATE OF

SS:

COUNTY OF

The undersigned, being duly sworn upon his oath, states or affirms that he is the applicant (or duly authorized representative of the applicant herein named,

to make this affidavit) and that he has read the foregoing statemants and that to the best of his knowledge and belief they are true and correct and that he

will comply with all laws and regulations of the Board of Animal Health pertaining to his business.

Date signed (mo., day, yr.)

Signature of Notary Public

Signature of applicant

Printed or typed name of Notary Public

Signature of applicant's representative

Date signed (mo., day, yr.)

County of residence

Date subscribed and sworn to (Notary Public)

Date commission expires