REGISTRATION FOR PRIVATE LABEL DISTRIBUTORS AHS-09-82

REGISTRATION FOR PRIVATE LABEL DISTRIBUTORS

INSTRUCTIONS: Submit this application to the Director, Meat and Poultry Inspection, Louisiana Department of Agriculture & Forestry, 5825 Florida Blvd., Suite 4003, Baton Rouge, LA 70806. Complete all sections. If a section is not applicable, enter "N/A" or "None". If additional space is needed for any item, attach sheet and number the item.
NAME OF APPLICANT
COMPANY NAME
ADDRESS

MAILING AND PHYSICAL ADDRESS

Street Address Line 2

CITY STATE ZIPCODEState / Province

Postal / Zip Code
PHONE
Please enter a valid phone number.Format: (000) 000-0000.
EMAIL
NAME OF PERSONS CHIEFLY RESPONSIBLE FOR BUSINESS
COMPANY NAME
ADDRESS

MAILING ADDRESS INDICATE IF SAME AS ABOVE

Street Address Line 2

CITY STATE ZIPCODEState / Province

Postal / Zip Code
PHONE
Format: (000) 000-0000.
EMAIL
PROCESSING ESTABLISHMENT(S) RESPONSIBLE FOR CONTROL OF PRIVATE LABEL(S):
LOCATIONS PRODUCT WILL BE STORED
PHYSCIAL ADDRESS

PHYSICAL ADDRESS

Street Address Line 2

CITY STATE ZIP CODEState / Province

Postal / Zip Code
PRIMARY CONTACT
SIGNATURE OF APPLICANT
DATE

MonthDayYear
Date
Should be Empty: