Form Is-10 "Application for Public Warehouse License / Renewal of Public Warehouse License" - Idaho

Form IS-10 is a Idaho Department of Agriculture form also known as the "Application For Public Warehouse License / Renewal Of Public Warehouse License". The latest edition of the form was released in March 1, 2011 and is available for digital filing.

Download an up-to-date Form IS-10 in PDF-format down below or look it up on the Idaho Department of Agriculture Forms website.

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IS-10
03/11
IDAHO STATE DEPARTMENT OF AGRICULTURE
WAREHOUSE CONTROL PROGRAM
2270 OLD PENITENTIARY ROAD
PO BOX 790
BOISE, ID 83701
For office use only
_____APPLICATION FOR PUBLIC WAREHOUSE LICENSE
AMOUNT RECEIVED
_____RENEWAL OF PUBLIC WAREHOUSE LICENSE
LICENSE NUMBER
The applicant, as a condition of receiving a license, agrees to comply with and abide by the terms of Title 69, Chapter 2, Idaho
Code and rules thereunder. Upon license suspension or license revocation of their Warehouse license, the licensee shall surrender,
upon demand, his Warehouse license and all unissued negotiable warehouse receipts to the Idaho State Department of Agriculture.
1. Full Legal Name of Applicant _____________________________________________________________________________
2. DBA (if any) __________________________________________________________________________________________
3. Contact Name __________________________________________________
4. Phone # ____________________________
5. Business mailing address _________________________________________________________________________________
6. Business phone # _________________________________ 7. Business fax # ______________________________________
8. Business e-mail address: ___________________________________________ 9. Website ___________________________
10. Idaho Contact (if different from above)* _____________________________ 11. Phone # ___________________________
License(s) will be sent to the Idaho Contact for posting in Idaho facilities or to the Contact in 3 above if no Idaho contact is given.
*
12. Idaho Mailing Address (if different from above) ______________________________________________________________
13. Idaho phone # (if different from above) ______________________________ 14. Idaho fax #________________________
15. Parent company (if applicable) ___________________________________________________________________________
16. Parent co. principal business mailing address _______________________________________________________________
17. Parent company phone #____________________________ 18. Parent company fax # ______________________________
19. Enter all physical addresses where business is conducted or delivery occurs by Idaho producers (or attach a list):
_______________________________________________________________________________COUNTY_________________
_______________________________________________________________________________COUNTY_________________
_______________________________________________________________________________COUNTY_________________
_______________________________________________________________________________COUNTY_________________
20. The applicant is an:
INDIVIDUAL
PARTNERSHIP
CORPORATION
LLC
INDIVIDUAL
21. If an individual, list name and address (if different from above)
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
PARTNERSHIP
22. If a partnership, list names and addresses of partners:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
IS-10
03/11
IDAHO STATE DEPARTMENT OF AGRICULTURE
WAREHOUSE CONTROL PROGRAM
2270 OLD PENITENTIARY ROAD
PO BOX 790
BOISE, ID 83701
For office use only
_____APPLICATION FOR PUBLIC WAREHOUSE LICENSE
AMOUNT RECEIVED
_____RENEWAL OF PUBLIC WAREHOUSE LICENSE
LICENSE NUMBER
The applicant, as a condition of receiving a license, agrees to comply with and abide by the terms of Title 69, Chapter 2, Idaho
Code and rules thereunder. Upon license suspension or license revocation of their Warehouse license, the licensee shall surrender,
upon demand, his Warehouse license and all unissued negotiable warehouse receipts to the Idaho State Department of Agriculture.
1. Full Legal Name of Applicant _____________________________________________________________________________
2. DBA (if any) __________________________________________________________________________________________
3. Contact Name __________________________________________________
4. Phone # ____________________________
5. Business mailing address _________________________________________________________________________________
6. Business phone # _________________________________ 7. Business fax # ______________________________________
8. Business e-mail address: ___________________________________________ 9. Website ___________________________
10. Idaho Contact (if different from above)* _____________________________ 11. Phone # ___________________________
License(s) will be sent to the Idaho Contact for posting in Idaho facilities or to the Contact in 3 above if no Idaho contact is given.
*
12. Idaho Mailing Address (if different from above) ______________________________________________________________
13. Idaho phone # (if different from above) ______________________________ 14. Idaho fax #________________________
15. Parent company (if applicable) ___________________________________________________________________________
16. Parent co. principal business mailing address _______________________________________________________________
17. Parent company phone #____________________________ 18. Parent company fax # ______________________________
19. Enter all physical addresses where business is conducted or delivery occurs by Idaho producers (or attach a list):
_______________________________________________________________________________COUNTY_________________
_______________________________________________________________________________COUNTY_________________
_______________________________________________________________________________COUNTY_________________
_______________________________________________________________________________COUNTY_________________
20. The applicant is an:
INDIVIDUAL
PARTNERSHIP
CORPORATION
LLC
INDIVIDUAL
21. If an individual, list name and address (if different from above)
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
PARTNERSHIP
22. If a partnership, list names and addresses of partners:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
CORPORATION or LIMITED LIABILITY COMPANY
23. If Corporation or Limited Liability Company, list names and business addresses of officers (or attach a list):
President/Member_________________________________________Address__________________________________________
Vice President /Member_____________________________________Address__________________________________________
Secretary / Member ________________________________________Address__________________________________________
Treasurer / Member ________________________________________Address__________________________________________
General Manager / Member _________________________________Address__________________________________________
CEO / Member ___________________________________________Address__________________________________________
24. If this application is for a Partnership, Limited Liability Company (LLC), or Corporation, has your business or firm name
been recorded with the Secretary of State’s Office?
___________YES ___________NO
25. Date and state where legal organizational papers were filed: ____________________________________________________
26. In the past 12 months have the officers of the applicant changed, or has the ownership changed by more than 10%? If yes,
please explain.
___________YES ___________NO
27. Within the past three years has the applicant or any of its officers, directors, or owners owning at least ten percent (10%) of
the applicant been convicted of a felony involving violations of any state warehouse or grain dealer laws or the United States
Warehouse Act, or had a claim ordered or collected on a bond or other surety required by state or federal warehouse or grain
dealer laws? If yes, please explain.
___________YES ___________NO
28. Within the past three years has the applicant or any of its officers, directors, or owners owning at least ten percent (10%) of the
applicant filed for financial relief from creditors under any state or federal bankruptcy laws, or had any judgments entered
against them stemming from grain warehouse or grain dealing activities? If yes, please explain.
___________YES ____________NO
29. Do you enter into No Price Established (NPE) Contracts or Price Later (PL) Contracts with producers?
___________YES ___________NO
30. What agricultural commodities do you handle? _______________________________________________________________
_____________________________________________________________________________________________________
31. Your fiscal year ends: _____________________________________
32. Name and address of bank(s) that handle your business account(s):
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
33. By my signature below, I certify that I have thoroughly read and fully understand and will abide by the provisions of Title 69,
Chapter 2, Idaho Code, and rules thereunder of the Idaho State Department of Agriculture. I further certify that all answers
and statements on this application are true and complete to the best of my knowledge. I understand that should an
investigation disclose untruthful or misleading answers, my application may be rejected and any Warehouse license issued to
me pursuant to Title 69 Chapter 2, Idaho Code, may be canceled at any time.
Name (Print): ________________________________________________________ Phone: _________________________
Position: ____________________________________________________________
Signature: ___________________________________________________________
Date: _________________________
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