Fillable Arizona Department of Agriculture Attention: Self-Inspection 1688 West (Arizona)

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Arizona Department of Agriculture Attention: Self-Inspection 1688 West (Arizona)

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Arizona Department of Agriculture
Attention: Self-Inspection
1688 West Adams
Phoenix, AZ 85007
Phone: (602) 542-6407
Fax: (602) 542-4290
Email: selfinspection@azda.gov
For Internal Use Only
Receive Postmark Date __________
New Expiration Date ____________
Processed Date ________________
Application for Self-Inspection Certificates:
Pursuant to ARS 3-1203, 3-1337
Instructions
This application is valid for two years. Please review and correct the information below. Unsigned forms are not valid.
Notify the Department within 30 days of any change to the information provided below and include the commercial
operation being sold, leased, transferred, or disposed of. For other physical locations, use additional sheets. Updates
are available at https://agriculture.az.gov/animals/animal-services-inspections/livestock-inspections/self-inspections.
Applicant Information
Business Name: _______________________________________________________________________________
Last Name: _________________________________________
First Name: ___________________________________
Email: __________________________________________________________
Phone 1: ________________
Phone 2: ________________
Fax: __________________
Mailing Address:________________________________________________________________________________
City: ____________________________________
State: __________
Zip: ____________
Physical Address (if different): ______________________________________________________________________
City: ____________________________________
State: __________
Zip: ____________
AZ Registered Brand #_____________
AZ Flock ID #___________________
National Premises ID #______________
Have you (the applicant) been convicted of a felony under ARS Title 3 within the last three years? ______________
If yes, Case Number: ____________
Court: _______________
Charge: ______________
Sentence: ____________
Authorized Signatures
Applicants may designate four individuals, in addition to the applicant, authorized to sign self-inspection certificates. Animal Services
Division must be notified immediately concerning any changes in signature authority.
Signature 1:
Printed Name
Signature
Signature 2:
Printed Name
Signature
Signature 3:
Printed Name
Signature
Signature 4:
Printed Name
Signature
Signature
I certify that the information submitted on these forms is true and correct to the best of my knowledge. I UNDERSTAND
THAT ALL COMPLETED OR VOIDED CERTIFICATES MUST BE RETURNED TO THE DEPARTMENT WITHIN 10
DAYS AFTER THE END OF THE MONTH IN WHICH THE CERTIFICATE WAS USED OR VOIDED, ACCOMPANIED
BY ALL APPLICABLE FEES.
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Arizona Department of Agriculture Attention: Self-Inspection 1688 West (Arizona)

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Completed 20 July 2020

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