AHS-20-77 APPLICATION FOR LOUISIANA DEALER PERMIT

APPLICATION FOR LOUISIANA DEALER PERMIT
Section 1:
Official Name of Livestock Dealer:*
Complete Address/Location of Livestock Dealer:*
City:*
State:*
Zip Code:*
Phone:*
"Enter Number s Only"Format: (000) 000-0000.
Fax:
"Enter Numbers Only"
Email:*
example@example.com
Section 2:

Name and address of principal person(s) having financial interest in this livestock agency. In case of corporation, list officers.
1. Name:*
Address:*
City:*
State:*
Zip Code:*
Percent of business or stock owned:*
"Enter Numbers Only"
***Percentage of business or stock owned MUST total to 100 percent***

If percentage (on Name Line 1) doesn't total 100 percent, please complete lines 2 and 3.
2. Name:
Address:
City:
State:
Zip Code:
Percent of business or stock owned:
"Enter Numbers Only"
3. Name:
Address:
City:
State:
Zip Code:
Percent of business or stock owned:
"Enter Numbers Only"
Applicant:
Signature:*

Clear
Date*

MonthDayYear
Name:*
Title:*
Calculation
Should be Empty: