Application For Registration And License Under The Animal And Poultry By-Products Disposal Act Of 1964 - Mississippi Department Of Agriculture And Commerce

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MISSISSIPPI DEPARTMENT OF AGRICULTURE AND COMMERCE

Meat Inspection Division, P.O. Box 1609, Jackson, MS 39215-1609

(601) 359-1191 FAX (601) 359-1105

APPLICATION for REGISTRATION and LICENSE under the ANIMAL AND POULTRY BY-PRODUCTS

DISPOSAL ACT OF 1964

Name of Business

Location of Establishment County

Address

Street number or road directions

Name and Address of Owner(s)

Name of Operator or Manager

Address

Name of Lessor or Lessee

Address

Subsidiaries operating in the establishment

Location of any establishments and facilities used in connection with this business

When did this business begin operation?

Has license or permit of this establishment ever been refused, revoked or suspended?

Describe completely and concisely the business carried on

10.

List finished products

11.

Estimated number pounds processed monthly

12.

Method of disposal or processing of poultry by-products and/or bodies of dead animals

13.

Method of transportation of by-products and material to be rendered

14.

Number and kind of vehicles used in transportation of rendering materials and products

I, the undersigned, do hereby state on oath that the facts set forth in the foregoing application are true and correct.

Signature

Title

Sworn to and subscribed before me on this

day of

SEAL

Notary Public

Attach blue print or drawing to scale of establishment. Enclose recent photograph of building if available. Enclose fee of $50.00 per

establishment, plus $5 for each vehicle unit and $5 for each substation (Please do not mail cash).

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DO NOT WRITE IN THIS SPACE

Plant Survey:

Date

Inspected by:

Disposition:

EQUAL OPPORTUNITY IN EMPLOYMENT AND SERVICES