COMMERCIAL FEED REGISTRATION APPLICATION
Application is hereby made in accordance with and subject to the provisions of Connecticut General Statutes Sections 22-118K through 22-118v, for registration of
commercial feed products. All registrations shall expire on December thirty-first of each year. Submitted as part of this application is one (1) tag or label (or facsimile of
proposed label) for each new or revised product only. Acceptance of submitted application does not denote automatic acceptance of submitted label. A check payable to
the ''Connecticut Department of Agriculture'' must accompany this application. Please allow at least 2 weeks for label review and processing.
Incomplete applications and submitted payment will be returned for completion and resubmission.
Registration Number
FED - ___________
Federal Employer
Identification # or
(or Canadian GST #)
Business Type (Complete one)
Sole Proprietor - Owner Name
____________________________
Partnership - Principal Partner Name
_______________________________
Corporation - President Name
____________________________
LLC - Principal Member Name
____________________________
Registrant/ Agent / Manufacturer (All correspondence will be mailed here)
If you are registering on behalf of another company,
list that contact information here
Registrant Mailing Address (Street / P.O. Box)
Company Address (Street / P.O. Box)
Registrant Telephone Number
Please check box if additional new products are listed on the reverse side.
Total number of products Total fee
to be registered: _______________ due: $ ____________________
I HEREBY CERTIFY THAT: 1. The information appearing on these labels or facsimiles is true and correct in every respect
2. The application is made for and in behalf of the above named company
Printed name of applicant Signature of applicant Title Date
PLEASE RETURN: (1) This completed application
(2) One paper label for each new or revised product
(3) Check payable to “Connecticut Department of Agriculture”
Registration Expiration
12/31/20
CT Registration #FED - ______
NEW REGISTRATION
ADD NEW PRODUCTS
to existing registration
Registration Expiration: 12/31/20
State of Connecticut
Department of Agriculture
450 Columbus Boulevard, Suite 702
Hartford, CT 06103
Licensing (860) 713
-
2512
Calculated @$80.00 per product
