Fillable Form 18496 - Application For Livestock Dealer License printable pdf download

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INDIANA STATE BOARD OF ANIMAL HEALTH

APPLICATION FOR LIVESTOCK DEALER LICENSE

4154 N. Keystone Ave.

State Form 18496 (R7 / 5-10)

Indianapolis, Indiana 46205

Telephone: (317) 544-2400

Fax number: (317) 542-1415

INSTRUCTIONS:

Use ink or type all information.

Every dealer is required to be licensed under this act as required by Indiana Code 15-17-1 and shall keep such records, accounts and memoranda

as shall fully and correctly disclose all purchases, sales or transfers involving livestock transactions consummated in connection with his business.

Name of person, firm or corporation

Date of birth (if an individual) (month, day, year)

Telephone number

Address where business will be conducted (number and street, city, state, and ZIP code)

(

)

County of address where business will be conducted

Name of contact person within the organization (if different than above)

Principal address of contact person (if different than above) (number and street, city, state, and ZIP code)

Nature of business enterprise

Individual dealer

Packer buying station

New application

Stockyards

Packer

Auction market

Concentration point

Order buyer

Renewal

Business status of firm

Is the area where business will be

If a new application or a change of ownership, send a copy

Individual

Partnership

Corporation

conducted zoned for such business?

of approval / contract from government agency that granted

zoning approval / contract for location of business.

Limited Liability Company

Yes

Limited Liability Partnership

Have you ever been convicted of having

Are you registered and bonded

Are you / your agents now under any suspension or other

committed a felony?

with USDA-P&SA?

disciplinary order issued by the Secretary of Agriculture of

Yes

the U.S. pursuant to the Packers and Stock Yards Act (7 U.S.C.)

Yes

Amount received for consigned livestock sold on

Amount paid for livestock purchased in Indiana during

Are scales maintained in Indiana and utilized in weighing of

commission during previous

previous calendar year.

livestock purchased or sold in Indiana?

Yes

calendar year

Number of head purchased during the previous calendar year at this facility, or number of head purchased covered by this license.

Hogs

Cattle

Horses/Mules

Sheep/Goats

Deer

Llama

Ostrich/Emu

All Other

Buffalo

Number of head of consigned livestock sold on commission during previous calendar year.

Hogs

Cattle

Horses/Mules

Sheep/Goats

Deer

Llama

Buffalo

Ostrich/Emu

All Other

If business is to be transacted by a manager, supervisor or resident agent other than the corporate officer as shown above, indicate full name, title and complete address.

1. Name

Title

Date of birth (month, day, year)

Home Address (number and street, city, state, and ZIP code)

List full names and complete addresses of all persons who will act as agents or representatives in the actual buying or selling (attach separate sheet if necessary).

1. Name

Date of birth (month, day, year)

Home Address (number and street, city, state, and ZIP code)

2. Name

Date of birth (month, day, year)

Home Address (number and street, city, state, and ZIP code)

3. Name

Date of birth (month, day, year)

Home Address (number and street, city, state, and ZIP code)

NOTARY CERTIFICATE

STATE OF

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