FI-0152 REV (3/2018)
Michigan Department of Agriculture and Rural Development
P.O. Box 30776, Lansing, MI 48909 • 800-292-3939
In accordance with 2000 Public Act No. 92, as amended.
Water Bottling Registration Application
License Year Ending: 4/30/_____ Status:
New
Renewal
No Longer Needed
If Renewal, Unique ID or Registration No. of Establishment: _________________________
Business/Individual Information
Business or Individual Name:________________________________________________
Business or Individual Address:______________________________________________
City:________________________________________________ State: _______________
County:______________________________________________ Zip:_______________
Business Phone: (_____)_____________ Business Fax:(_____)____________________
Blank Space
Business Email:__________________________________________________________
For Official Use Only
Mailing address if different from above: Street or P.O. Box:___________________________
________________________________________________________________________________________________________
City:_____________________________________ State: ______ County:__________________________ Zip:_______________
Corporate/Owner Information
Ownership Type:
Sole Ownership
Joint Tenant
Partnership
L.L.C.
Corporation
Corporation: _______________________________________________________________________
Owner/President (CEO) Name:______________________________________________________________________________
Street Address of Corporation or Owner:_______________________________________________________________________
City:______________________________________________________________________ State: _______ Zip:_____________
Business Phone: (_____)_____________ Business Fax:(_____)______________ Business Email:________________________
Federal/Tax ID #
Emergency Contact: (_____)_____________ Cell Phone: (_____)______________
Bottling Plant Information
Location of Plant:_______________________________________________St. Address:_________________________________
City:________________________________________ State: ____ Zip:_________ County: _______________________________
Identification of water source (i.e. spring; municipality; well): ________________________________________________________
Date of Michigan Department of Environmental Quality source water approval letter: ____/____/____
On the reverse side of this application please list all labels being registered. A flat rate discount can be applied for a bottler
registering more that 100 labels, see reverse for details.
License Fees
AOBJ: 0110
(Please indicate all that apply)
Registration fee is $25.00 each. Indicate total number units including reverse side: ______ @ $25.00= ___________
Payment Method: Check/Money Order No._________________________________________ Amount enclosed: _______________
Please make check/money order payable to the State of Michigan and submit to the address at the top of the page.
Signature:__________________________________________________ Date:___________________
Application continues
Please print your name here:___________________________________________________________
on the back of this form
Title:___________________________________________________
www.michigan.gov/mda-licensing
FI-0152 REV (3/2018)
Michigan Department of Agriculture and Rural Development
P.O. Box 30776, Lansing, MI 48909 • 800-292-3939
In accordance with 2000 Public Act No. 92, as amended.
Water Bottling Registration Application
License Year Ending: 4/30/_____ Status:
New
Renewal
No Longer Needed
If Renewal, Unique ID or Registration No. of Establishment: _________________________
Business/Individual Information
Business or Individual Name:________________________________________________
Business or Individual Address:______________________________________________
City:________________________________________________ State: _______________
County:______________________________________________ Zip:_______________
Business Phone: (_____)_____________ Business Fax:(_____)____________________
Blank Space
Business Email:__________________________________________________________
For Official Use Only
Mailing address if different from above: Street or P.O. Box:___________________________
________________________________________________________________________________________________________
City:_____________________________________ State: ______ County:__________________________ Zip:_______________
Corporate/Owner Information
Ownership Type:
Sole Ownership
Joint Tenant
Partnership
L.L.C.
Corporation
Corporation: _______________________________________________________________________
Owner/President (CEO) Name:______________________________________________________________________________
Street Address of Corporation or Owner:_______________________________________________________________________
City:______________________________________________________________________ State: _______ Zip:_____________
Business Phone: (_____)_____________ Business Fax:(_____)______________ Business Email:________________________
Federal/Tax ID #
Emergency Contact: (_____)_____________ Cell Phone: (_____)______________
Bottling Plant Information
Location of Plant:_______________________________________________St. Address:_________________________________
City:________________________________________ State: ____ Zip:_________ County: _______________________________
Identification of water source (i.e. spring; municipality; well): ________________________________________________________
Date of Michigan Department of Environmental Quality source water approval letter: ____/____/____
On the reverse side of this application please list all labels being registered. A flat rate discount can be applied for a bottler
registering more that 100 labels, see reverse for details.
License Fees
AOBJ: 0110
(Please indicate all that apply)
Registration fee is $25.00 each. Indicate total number units including reverse side: ______ @ $25.00= ___________
Payment Method: Check/Money Order No._________________________________________ Amount enclosed: _______________
Please make check/money order payable to the State of Michigan and submit to the address at the top of the page.
Signature:__________________________________________________ Date:___________________
Application continues
Please print your name here:___________________________________________________________
on the back of this form
Title:___________________________________________________
www.michigan.gov/mda-licensing
Label Information
(Please copy and attach additional pages as needed)
Special Instructions for Firms with over 100 Brands of Bottled Water
The Michigan Food Law, PA 92 of 2000, as amended, requires a $25 registration fee for each distinct brand or label produced by a
bottled water manufacturer. The Michigan Department of Agriculture, Food and Dairy divisions has determined that each distinct
label you produce for your customers (such as schools, clubs, and individual businesses) represents a separate “brand”. For
example, “Kent Schools Drinking Water” and “Kent Schools Spring Water”, represent two (2) brands or labels of water. However, due
to the fact that the potential exists for hundreds of such products, we will administratively handle these situations in the following
manner:
1. Instead of paying a yearly registration fee of $25 for each customer label and each type of water, you may choose to pay a “flat”
yearly fee based on 100 brands (100 x $25 = $2500). You may produce and distribute in Michigan an unlimited number of
brands above 100 once this flat fee is paid each year.
2. Your company’s responsible party information must continue to appear somewhere on each label (not necessarily on the
principal display panel).
3. You must submit a quarterly list of separate customer brands and types of water for Michigan customers under each brand to
this agency. This will serve as the list of registered brands. Failure to submit a complete list by the next renewal period may
negate this flat fee option.
4. The Michigan Department of Agriculture may revisit this option should any change in practice occur.
Label Information
ID of Bottler
Water Type
Example: Joe’s Water (Please attach copy of actual label)
Bottler company
Mineral, Spring, Purified
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