Indiana Premises Identification Registration
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INDIANA STATE BOARD OF ANIMAL HEALTH
Discovery Hall, Suite 100
INDIANA PREMISES IDENTIFICATION REGISTRATION
th
1202 East 38
Street
State Form 52009 (R8 / 2-15)
Indianapolis, Indiana 46205-2898
Telephone: 317-544-2400
Fax: 317-974-2011
INSTRUCTIONS:
Email:
animalid@boah.in.gov
1.
Please type or print legibly.
2.
Return forms to the above address.
3.
For questions, contact BOAH support at the above telephone number or e-mail address.
Purpose of this form (check one)
If update, enter premises identification number
Register a premises for the first time
Update information on a registered premises
PART I – PREMISES INFORMATION (ANIMAL LOCATION)
Name of business / farm (optional)
Name / description of premises (Example: “home,” “heifer place”)
Physical address of premises (No PO Box) (number and street, city, state, and ZIP code)
County
Is the premises’ physical address also a mailing address?
Yes
No
Legal land description (Required if no address applies)
Township: ____________________________
Range: ____________________________
Section: ____________________________
Geographic Information System (GIS) coordinates (Suggested if premises has no address)
Latitude: ______________________________
Longitude: ______________________________
Type of operation (check all that apply)
Farm / Production Unit / Stable
4-H Participant Only
Clinic
Laboratory
Slaughter Plant
Port of Entry
Market / Collection Point
Exhibition / Show Site
Zoo
Research Facility
Rendering
Quarantine Facility
Other: ___________________________________________________________________________________________________________
Species at premises for purposes other than 4-H (check all that apply)
Beef Cattle
Chickens
Swine
Sheep
Goats
Horses
Bison
Dairy Cattle
Turkeys
Waterfowl
Deer
Elk
Other Livestock: ________________________________
Species at premises for 4-H purposes only (check all that apply)
Beef Cattle
Chickens
Swine
Sheep
Horses
Dairy Cattle
Turkeys
Waterfowl
Goats
Other Livestock: ________________________________________
PART II – CONTACT INFORMATION
This section specifies the contact information for an operation. Should an animal health emergency occur, the individual(s) listed will be contacted for
appropriate notification. This process is essential to protecting the industry from the spread of disease.
Name of primary contact (first, middle, last)
Mailing address of primary contact (number and street, city, state, and ZIP code)
County
Check if same as premises’
physical address. (No PO Box)
Business telephone number
Home telephone number
Cellular telephone number
Fax number
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)
(
)
(
)
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E-mail address
Name of secondary contact (first, middle, last)
Mailing address of secondary contact (number and street, city, state, and ZIP code)
County
Check if same as premises’
physical address. (No PO Box)
Business telephone number
Home telephone number
Cellular telephone number
Fax number
(
)
(
)
(
)
(
)
E-mail address
If you have more than one premises (animal locations), please complete page 2 of this form.
Page 1 of 2
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