New Listing For Pet And/or Specialty Pet Food Products Distributed In Minnesota Form printable pdf download

Dairy and Food Inspection Division, Ph. 651-201-6027

NEW LISTING FOR PET AND/OR SPECIALTY PET FOOD PRODUCTS DISTRIBUTED IN

MINNESOTA

JULY 1, 20__ THROUGH JUNE 30, 20__

Minn. Stat. Sec. 25.31-43

Note: A current Minnesota Commercial Feed License is required for any person listing pet or specialty pet food products.

Current Minnesota Commercial Feed License Number:____________________

License Holder/Guarantor Legal Name

Mailing Address Name (if different from License Holder)

DBA (Doing Business As)

Mailing Address

Physical Street Address (No PO Box)

City, State, Zip Code

County

License Holder/Guarantor Telephone Number

25.341 LICENSING. Subdivision 1.

A Minnesota Commercial Feed License is required for any person listing pet/specialty pet food products.

This form is for Pet and Specialty Pet Food Products sold EXCLUSIVELY in packages of 10 LBS OR LESS.

Subd. 20. Pet.

"Pet" means a domesticated dog or cat normally maintained in or near the household of its owner.

"Specialty pet" means a domesticated animal normally maintained in a cage or tank, including, but not limited to, a gerbil, hamster, canary, psittacine bird,

Subd. 22. Specialty pet.

mynah, finch, tropical fish, goldfish, snake, or turtle. "Specialty pet" does not include a dog, cat, horse, rabbit, or wild bird.

Please verify/include the following information to help process your application/labels:

• The guarantor, city, and state listed on your labels must match the license holder, city, and state on your license.

• A complete list of product names.

• Complete and LEGIBLE labels for all products.

For specific questions about product listing, please contact us at 651-201-6027 or see our website at

Listing Fee

Number of Products

Amount

Amount Due

Pet Food (Dog or Cat)

X $100.00

600280(3200)

Specialty Pet Food (see above)

X $100.00

600285(3200)

X $100.00

600280(3520)

Penalty Fee*

*(Per product and in addition to the listing fee. Applies if the annual renewal is

not received before July 1 or if an unlisted product is distributed in Minnesota.)

TOTAL $________________

Return this form with your check made payable to:

MINNESOTA DEPARTMENT OF AGRICULTURE

Attn: Cashier

625 Robert Street North

Saint Paul, MN 55155-2538

Licenses are not transferable and fees are not refundable.

I hereby certify that the information contained in and submitted with this form is true and correct.

For Office Use Only

Signature: ________________________________________

Date: ____________________

Name (Please print): ________________________________

Title: ____________________

Contact Telephone: ________________________ Fax Number: _______________________

E-mail Address: ______________________________________________________________

In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request by calling 651-201-6000. TTY users can

call the Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.

AG-01368 (07/15)