AHS-20-69 BUSINESS/FARM APPLICATION FOR PREMISES ID NUMBER

BUSINESS/FARM APPLICATION FOR PREMISES ID NUMBER
ACCOUNT INFORMATION:
Business/Farm Name:*
Owner's Name:*
Alternate Contact Name:*
Mailing Address:*
City:*
State:*
Zip Code:*
Parish:*
Business Phone:*
"Enter Numbers Only"
Cell Phone:*
"Enter Numbers Only"
Email address (Required):*
example@example.com
Fax:
Signature of Applicant/Authorized Agent:*

Clear
Date:*

MonthDayYear
LOCATION OF ANIMALS:

This is the primary location where livestock reside. If animals are managed as separate herds on separate locations without commingling, register multiple premises.
Physical (911) Address:*
City:*
State:*
Zip Code:*
Parish:*
GEO Coordinates:
Latitude:*
Longitude:*
PRIMARY BUSINESS FUNCTION (Please check only one):*

Producer Unit/FarmExhibitionLaboratoryClinicMarket/Collection PointNon Producer ParticipantPort of EntryTagging SiteQuarantine FacilityOther
SPECIES OF ANIMALS (Please check all that apply):*

CattleBisonHorsesSheepGoatsPoultrySwineDeerElkCamelsEmuOther
Complete additional submissions for additional locations of animals.
Print and attach a second sheet for additional locations of animals.

Return completed form by mail or email to:

Louisiana Department of Agriculture & Forestry

Animal Health & Food Safety

5825 Florida Blvd., Suite 4000

Baton Rouge, LA. 70806

Email: PremisesID@ldaf.state.la.us
Should be Empty: