Bonded Weighmaster'S License For A Business Or Individual Form (Page 3 of 6) in pdf

What is the primary property, commodity, produce or article to be weighed or measured by business or individual?

____________________________________________________________________

Type of Scale (weighing device):

a. Name _________________________

b. Serial No. ______________________________

c. Capacity ______________________

d. Date of last official test ____________________

Has Business or Individual ever held a license or authorization to perform similar duties to those for which this

application is made? □ Yes □ No

State business or trade names used, if any _____________________________________ where filed ___________

Principal office if State of Mississippi ______________________________________________

Is Business or Individual a subsidiary of or affiliated in any way with any other corporation □ Yes □ No If yes,

state details _______________________________________

Domestic __________________________ Foreign __________________________________

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 _________________________________, 20_________________

__________________________________

________________________________________

Full name of applicant

Title

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 ___________________, 20_________.

My Commission expires ___________________

______________________________

Notary Public

Bonded Weighmaster'S License For A Business Or Individual Form Page 3