Form PI-216 "Wholesale Potato Dealer License Application" - Michigan

What Is Form PI-216?

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 October 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-216 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-216 "Wholesale Potato Dealer License Application" - Michigan

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PI-216 (10/17)
Michigan Department of Agriculture & Rural Development
P.O. Box 30776, Lansing, MI 48909-8246 • 517-284-5771
FAX: 517-284-0458
In accordance with 1964 Public Act 158, as amended.
Wholesale Potato Dealer License Application
License Year Ending: May 31
Status:
New
Renewal
No Longer Needed
If Renewal, License No. of Establishment: _____________________________________
Business Information
Business Name:__________________________________________________________
Business Address:________________________________________________________
City:________________________________________________ State:______________
County:______________________________________________ Zip:_______________
Business Phone:(_____)_____________ Business Fax:(_____)____________________
Blank Space
Business Email:__________________________________________________________
For Offi cial Use Only
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: _______________________________________________________________________________________
Owner/President (CEO) Name:______________________________________________________________________________
Street Address of Corporation or Owner:_______________________________________________________________________
City:_______________________________________________________________________ State:_______ Zip:_____________
Phone: (_____)_____________ Fax: (_____)_______________ Email:______________________________________________
Federal/Tax ID #
Emergency Contact: (_____)_____________ Cell Phone: (_____)_____________
License Fees
(Non-refundable)
AOBJ: 1234
Wholesale Dealer License
$100
________
Identifi cation cards @
$5.00 each =________
Certifi ed license copies @
$5.00 each =________
Total
________
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:___________________
Please print your name here:__________________________________________________________
Application continues
Title:_____________________________________________________________________________
on the back of this form
www.michigan.gov/mda-licensing
PI-216 (10/17)
Michigan Department of Agriculture & Rural Development
P.O. Box 30776, Lansing, MI 48909-8246 • 517-284-5771
FAX: 517-284-0458
In accordance with 1964 Public Act 158, as amended.
Wholesale Potato Dealer License Application
License Year Ending: May 31
Status:
New
Renewal
No Longer Needed
If Renewal, License No. of Establishment: _____________________________________
Business Information
Business Name:__________________________________________________________
Business Address:________________________________________________________
City:________________________________________________ State:______________
County:______________________________________________ Zip:_______________
Business Phone:(_____)_____________ Business Fax:(_____)____________________
Blank Space
Business Email:__________________________________________________________
For Offi cial Use Only
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: _______________________________________________________________________________________
Owner/President (CEO) Name:______________________________________________________________________________
Street Address of Corporation or Owner:_______________________________________________________________________
City:_______________________________________________________________________ State:_______ Zip:_____________
Phone: (_____)_____________ Fax: (_____)_______________ Email:______________________________________________
Federal/Tax ID #
Emergency Contact: (_____)_____________ Cell Phone: (_____)_____________
License Fees
(Non-refundable)
AOBJ: 1234
Wholesale Dealer License
$100
________
Identifi cation cards @
$5.00 each =________
Certifi ed license copies @
$5.00 each =________
Total
________
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:___________________
Please print your name here:__________________________________________________________
Application continues
Title:_____________________________________________________________________________
on the back of this form
www.michigan.gov/mda-licensing
Local Agents or Buyers
(Attach more pages if needed)
An identifi cation card is required for each person authorized as an agent or buyer under this license.
Agent or Buyer Name:_____________________________________________________________________________________
Street Address:___________________________________________________________________________________________
City:_____________________________________ Michigan
County:__________________________ Zip:______________
Agent or Buyer Name:_____________________________________________________________________________________
Street Address:___________________________________________________________________________________________
City:_____________________________________ Michigan
County:__________________________ Zip:______________
Agent or Buyer Name:_____________________________________________________________________________________
Street Address:___________________________________________________________________________________________
City:_____________________________________ Michigan
County:__________________________ Zip:______________
Financial Security
(Bond or Irrevocable Letter of Credit )
A. If applicant is a new business that has not operated in Michigan, what is the estimated amount of business to be done
annually?
Cwt. Amount:______________
Dollar Amount: $ _____________
B. If applicant is a grower cooperative as defi ned in Sections 1(h) and 8(2) of P.A. 158 of 1964 as amended, insert here
the amount paid for potatoes purchased from or handled for NONMEMBERS during the month in which the maximum
volume of Michigan grown potatoes was bought or handled during the past calendar year.
Cwt. Amount:______________
Dollar Amount: $ _____________
C. All other applicants: Insert here the amount paid for Michigan grown potatoes purchased from or handled for growers
during the month in which the maximum volume of Michigan grown potatoes was bought or handled during the past
calendar year.
Cwt. Amount:______________
Dollar Amount: $ _____________
Bond or irrevocable letter of credit must be double the dollar amount listed in (A), (B), or (C) above but not less than
$10,000 or more than $100,000
Bond is currently on fi le with the Michigan Department of Agriculture & Rural
IF BONDED: (Check One)
Development
Bond Number:_______________________
Bond Amount $ _______________
Bond is enclosed with this application.
Surety Company/Agent Name:
___________________________________________________________________________
Street Address:__________________________________________________________________________________________
City:_____________________________________ Michigan
County:_________________Zip:_______________
IF IRREVOCABLE LETTER OF CREDIT: (Check One)
Letter of Credit is currently on fi le with the Michigan Department of Agriculture &
Rural Development
Letter of Credit Number:_______________ Letter of Credit Amount $ _____________
Letter of Credit is enclosed with this application.
Letter of Credit Number:_______________ Letter of Credit Amount $ _____________
Issuing Bank Name:
____________________________________________________________________________________
Street Address:_________________________________________________________________________________________
City:_____________________________________ Michigan
County:__________________________ Zip:_______________
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