Form FI-0153 "Water Dispensing Machine Registration Application" - Michigan

What Is Form FI-0153?

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 March 1, 2018;
  • 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 FI-0153 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 FI-0153 "Water Dispensing Machine Registration Application" - Michigan

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FI-0153 REV 3/2018
Michigan Department of Agriculture
P.O. Box 30776, Lansing, MI 48909 • 800-292-3939
In accordance with 2000 Public Act 92, as amended.
Water Dispensing Machine Registration Application
License Year Ending: 4/30/_____ Status:
New
Renewal
No Longer Needed
If Renewal, Unique ID or License 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: _______ County:_______________________ Zip:_____________
Business Phone: (_____)_____________ Business Fax:(_____)_______________ Business Email:_______________________
Federal/Tax ID No.
Emergency Contact: (_____)_____________ Cell Phone: (_____)_____________
Dispensing Machine Information
(Please list business(es) and location of water dispensing units below.)
Business Name:___________________________________St. Address:_____________________________________________
# of Units
Type of Water Dispensed
City:_________________________________, MI Zip:_______ County: _________________
Business Name:___________________________________St. Address:_____________________________________________
# of Units
Type of Water Dispensed
City:_________________________________, MI Zip:_______ County: _________________
(If you have more than two locations, please continue listings on the reverse side.)
License Fees
AOBJ: 0110
(Please indicate all that apply)
Dispensing 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-0153 REV 3/2018
Michigan Department of Agriculture
P.O. Box 30776, Lansing, MI 48909 • 800-292-3939
In accordance with 2000 Public Act 92, as amended.
Water Dispensing Machine Registration Application
License Year Ending: 4/30/_____ Status:
New
Renewal
No Longer Needed
If Renewal, Unique ID or License 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: _______ County:_______________________ Zip:_____________
Business Phone: (_____)_____________ Business Fax:(_____)_______________ Business Email:_______________________
Federal/Tax ID No.
Emergency Contact: (_____)_____________ Cell Phone: (_____)_____________
Dispensing Machine Information
(Please list business(es) and location of water dispensing units below.)
Business Name:___________________________________St. Address:_____________________________________________
# of Units
Type of Water Dispensed
City:_________________________________, MI Zip:_______ County: _________________
Business Name:___________________________________St. Address:_____________________________________________
# of Units
Type of Water Dispensed
City:_________________________________, MI Zip:_______ County: _________________
(If you have more than two locations, please continue listings on the reverse side.)
License Fees
AOBJ: 0110
(Please indicate all that apply)
Dispensing 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
Water Dispensing Machine Locations
(Please copy and attach additional pages as needed)
Units
Type of Water
Name of Business at which
Street Address of location
Per
County
machines are located
(Also include city and zip)
Dispensed
Location
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Indicate total number units including reverse side: ______ @ $25.00 = ___________
Total dispensing units
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