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____________________ ____________________ ____________________ ____________________

API-225 (Rev. 09/12)

PENNSYLVANIA DEPARTMENT OF AGRICULTURE

BUREAU OF PLANT INDUSTRY

DIVISION OF AGRONOMIC SERVICES

2301 North Cameron Street

Harrisburg, Pennsylvania 17110-9408

APPLICATION FOR A COMMERCIAL FEED LICENSE

_____ $25.00 Per Manufacturing Facility in PA

_____ $25.00 Per Guarantor

SEE INSTRUCTIONS ON BACK OF PAGE

APPLICATION IS HEREBY MADE FOR A LICENSE TO SELL FEED OR FEED INGREDIENTS IN PENNSYLVANIA

BUSINESS NAME COUNTY (IF IN PENNSYLVANIA)

STREET ADDRESS CITY STATE ZIP CODE

TELEPHONE NUMBER

MAILING ADDRESS IF DIFFERENT FROM ACCOUNT ADDRESS

EMAIL ADDRESS

CONTACT INFORMATION

*FOR MOBILE MILL ONLY

*VEHICLE INFORMATION: __________________________________________________________________________

(MAKE OF TRUCK) (MANUFACTURER’S NUMBER)

COMMERCIAL FEEDS ARE MANUFACTURED AT THE FOLLOWING LOCATION(S):

NAME ADDRESS

I verify that the above statements are true and correct to the best of my knowledge, information, and belief. I understand

that false statements are made subject to the penalties of 18 Pa.C.S. Section 4904 relatin g to unsworn falsification to

authorities and may result in criminal prosecution and suspension or revocation of my license.

I hereby agree to comply with the provisions of the Pennsylvania Commercial Feed Act and Rules promulgated thereunder.

Signature Title Date

The above named company is licensed to distribute Commercial Feed in Pennsylvania for the period ending December 31, 20______.

(License Fee) (Date Approved) (Control Number) (Program Specialist)

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INSTRUCTIONS FOR COMPLETING

THE COMMERCIAL FEED LICENSE APPLICATION

1. Print business name and address. This must be the same as that appearing on the bag, invoice

or label. If you want a separate mailing address, include the request along with the application.

2. List the location(s) of the Manufacturing facility(ies). If facilities are located in Pennsylvania,

they must have a commercial feed manufacturing license.

3. A responsible officer of the business must sign the application and indicate his/her title.

4. Submit fee of $25.00 per PA Manufacturing Facility or Guarantor

5. Submit a commercial feed product label for reference.

6. Make check(s) or money order(s) for the proper amount payable to:

COMMONWEALTH OF PENNSYLVANIA

7. Remit license fee and address all correspondence to:

PA DEPARTMENT OF AGRICULTURE

BUREAU OF PLANT INDUSTRY

DIVISION OF AGRONOMIC AND REGIONAL SERVICES

2301 NORTH CAMERON STREET

HARRISBURG PA 17110-9408

For more information, please contact the Bureau of Plant Industry at (717) 787-4843 or visit our

website, www.agriculture.state.pa.us. On the Home Page, select “Programs” and search for

“Commercial Feed.”

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