Form PI-233 "Agricultural Pesticide Dealer License Application" - Michigan

What Is Form PI-233?

This is a legal form that was released by the Michigan Department of Agriculture and Rural Development - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2017;
  • The latest edition provided by the Michigan Department of Agriculture and Rural Development;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form PI-233 by clicking the link below or browse more documents and templates provided by the Michigan Department of Agriculture and Rural Development.

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Download Form PI-233 "Agricultural Pesticide Dealer License Application" - Michigan

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PI-233 (9/17)
Michigan Department of Agriculture & R
ural Development
Application Date.: ____/____/____
P.O. Box 30776, Lansing, MI 48909-8246 • 517-284-5771
FAX: 517-284-0458
Issue Date: ____/____/____
In accordance with 1994 Public Act 451, as amended.
Expired Date: ____/____/____
Validation # __________________
Agricultural Pesticide Dealer License Application
License Year Ending: December 31 _______
Status:
New
Renewal
License No. of Establishments _________________
No Longer Needed
Business Information
Business Name:__________________________________________________________
Street Address:___________________________________________________________
City:________________________________________________ State: ______________
County:______________________________________________ Zip:_______________
Business Phone: (_____)_____________ Business Fax:(_____)____________________
Business. Email:__________________________________________________________
Mailing address if different from above: Street or P.O. Box:_________________________
_______________________________________________________________________
City:____________________________________ State:____________ County:______________________ Zip:_________________
Corporate/Owner Information
Ownership Type:
Corporation
Sole Ownership
Partnership
L.L.C.
Other: Specify_________________
Corporation Name: __________________________________________________________MI Corp. ID No._________________
Street Address of Corporation:_______________________________________________________________________________
City:_______________________________________________________________________ State: _______ Zip:____________
Phone: (_____)_____________ Fax:(_____)_______________ Email:______________________________________________
Federal/Tax ID No.
Emergency Contact: (_____)_____________ Cell Phone: (_____)_____________
Resident Agent Information
Resident Agent Name:________________________________________________ Bus. E-mail: ____________________________
Street Address:_______________________________________________ City:___________________________ State: _________
County:___________________________ Zip:_________ Bus. Phone: (_____)_____________ Bus. Fax:(_____)______________
Mailing address if different from above: Street or P.O. Box:___________________________________________________________
City:___________________________________________________________________________ State: ______ Zip: ___________
License Fees
(Non-refundable)
AOBJ: 0352
Dealer License Fee
$100
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.
Person in Charge Signature:_________________________________________________ Date:__________________________
Please print your name here:________________________________________________________________________________
Title:___________________________________________________________________________________________________
www.michigan.gov/mda-licensing
PI-233 (9/17)
Michigan Department of Agriculture & R
ural Development
Application Date.: ____/____/____
P.O. Box 30776, Lansing, MI 48909-8246 • 517-284-5771
FAX: 517-284-0458
Issue Date: ____/____/____
In accordance with 1994 Public Act 451, as amended.
Expired Date: ____/____/____
Validation # __________________
Agricultural Pesticide Dealer License Application
License Year Ending: December 31 _______
Status:
New
Renewal
License No. of Establishments _________________
No Longer Needed
Business Information
Business Name:__________________________________________________________
Street Address:___________________________________________________________
City:________________________________________________ State: ______________
County:______________________________________________ Zip:_______________
Business Phone: (_____)_____________ Business Fax:(_____)____________________
Business. Email:__________________________________________________________
Mailing address if different from above: Street or P.O. Box:_________________________
_______________________________________________________________________
City:____________________________________ State:____________ County:______________________ Zip:_________________
Corporate/Owner Information
Ownership Type:
Corporation
Sole Ownership
Partnership
L.L.C.
Other: Specify_________________
Corporation Name: __________________________________________________________MI Corp. ID No._________________
Street Address of Corporation:_______________________________________________________________________________
City:_______________________________________________________________________ State: _______ Zip:____________
Phone: (_____)_____________ Fax:(_____)_______________ Email:______________________________________________
Federal/Tax ID No.
Emergency Contact: (_____)_____________ Cell Phone: (_____)_____________
Resident Agent Information
Resident Agent Name:________________________________________________ Bus. E-mail: ____________________________
Street Address:_______________________________________________ City:___________________________ State: _________
County:___________________________ Zip:_________ Bus. Phone: (_____)_____________ Bus. Fax:(_____)______________
Mailing address if different from above: Street or P.O. Box:___________________________________________________________
City:___________________________________________________________________________ State: ______ Zip: ___________
License Fees
(Non-refundable)
AOBJ: 0352
Dealer License Fee
$100
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.
Person in Charge Signature:_________________________________________________ Date:__________________________
Please print your name here:________________________________________________________________________________
Title:___________________________________________________________________________________________________
www.michigan.gov/mda-licensing