AHS-17-03 NEW REGISTRATION OF COMMERCIAL FEED MANUFACTURERS AND GUARANTORS

NEW REGISTRATION OF COMMERCIAL FEED MANUFACTURERS AND GUARANTORS
{Pursuant to Louisiana Revised Statutes Title 3, Chapter 10-A, Part II, §1393 (A)}
Business Name*
Physical Address*
City*
State*
Zip*
Parish/County*
Mailing Address*
City*
State*
Zip*
Parish/County*
Phone*
"Enter Numbers Only"
Fax
"Enter Numbers Only"
Email*
example@example.com
Does your company only distribute commercial feed in the state weighing ten pounds or less making it a Speciality Fee company?*

YesNo
- Do not staple payment to your application. Payment may be submitted via online transaction, check, or money order. DO NOT MAIL CASH.
- Make payment to: LOUISIANA DEPARTMENT OF AGRICULTURE & FORESTRY.
- Mail to: LDAF Revenue, 5825 Florida Blvd., Suite 1003, Baton Rouge, LA 70806
Print Name*
Title*
Signature*

Clear
Date*

MonthDayYear
CERTIFICATE OF REGISTRATION

This certifies that the Commercial Feed manufacturer or guarantor identified on this application will be registered with the Louisiana Department of Agriculture and Forestry for the fiscal year, July 1st through June 30th, and the applicable fees listed below have been paid in full.
Reg Fee
$40.00 COMPANY REGISTRATION FEE
Field auto populates
$200.00 ANNUAL SPECIALTY FEE (in lieu of inspection fees) if applicable
Field auto populates
TOTAL DUE
Should be Empty: