"Nova Scotia Premises Identification Program Application Form" - Nova Scotia, Canada

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Download "Nova Scotia Premises Identification Program Application Form" - Nova Scotia, Canada

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Clear Form
Nova Scotia Premises Identification Program
Application Form
This form may be used to apply for a Premises Identification (PID) number or to update information related
to an existing Premises Identification number. Please remember to request separate PID numbers for
separate parcels of land.
• To apply for a new PID, please complete all areas of the form.
• Each premises must have at least a landowner and primary emergency contact identified.
• For an update to an existing PID, please complete all information areas that have been modified and
sign the consent to disclose information area at the end of the form.
• More information can be found at
novascotia.ca/agri/premisesid
q This is an application for a new PID number  q This is an update for an existing PID number
1. Contacts 
Landowner and Primary Emergency Contact Must Be Identified
Add any additional contacts on an additional sheet of paper or make an additional copy of this page.
Name
First Name
Middle Name
Last Name
Business/Farm Name 
Mailing Address
Nova Scotia
City/Town/Community
Province
Postal Code
Phone
Home Phone
Work Phone
Mobile Phone
Fax
E-mail 
Relationship to premises
q Secondary Emergency Contact
q Landowner
(select all that apply)
q Primary Emergency Contact
q Other-Specify 
Name
First Name
Middle Name
Last Name
Business/Farm Name 
Mailing Address
Nova Scotia
City/Town/Community
Province
Postal Code
Phone
Home Phone
Work Phone
Mobile Phone
Fax
E-mail 
Relationship to premises
q Secondary Emergency Contact
q Landowner
(select all that apply)
q Primary Emergency Contact
q Other-Specify 
Clear Form
Nova Scotia Premises Identification Program
Application Form
This form may be used to apply for a Premises Identification (PID) number or to update information related
to an existing Premises Identification number. Please remember to request separate PID numbers for
separate parcels of land.
• To apply for a new PID, please complete all areas of the form.
• Each premises must have at least a landowner and primary emergency contact identified.
• For an update to an existing PID, please complete all information areas that have been modified and
sign the consent to disclose information area at the end of the form.
• More information can be found at
novascotia.ca/agri/premisesid
q This is an application for a new PID number  q This is an update for an existing PID number
1. Contacts 
Landowner and Primary Emergency Contact Must Be Identified
Add any additional contacts on an additional sheet of paper or make an additional copy of this page.
Name
First Name
Middle Name
Last Name
Business/Farm Name 
Mailing Address
Nova Scotia
City/Town/Community
Province
Postal Code
Phone
Home Phone
Work Phone
Mobile Phone
Fax
E-mail 
Relationship to premises
q Secondary Emergency Contact
q Landowner
(select all that apply)
q Primary Emergency Contact
q Other-Specify 
Name
First Name
Middle Name
Last Name
Business/Farm Name 
Mailing Address
Nova Scotia
City/Town/Community
Province
Postal Code
Phone
Home Phone
Work Phone
Mobile Phone
Fax
E-mail 
Relationship to premises
q Secondary Emergency Contact
q Landowner
(select all that apply)
q Primary Emergency Contact
q Other-Specify 
Name
First Name
Middle Name
Last Name
Business/Farm Name 
Mailing Address
Nova Scotia
City/Town/Community
Province
Postal Code
Phone
Home Phone
Work Phone
Mobile Phone
Fax
E-mail 
Relationship to premises
q Secondary Emergency Contact
q Landowner
(select all that apply)
q Primary Emergency Contact
q Other-Specify 
Name
First Name
Middle Name
Last Name
Business/Farm Name 
Mailing Address
Nova Scotia
City/Town/Community
Province
Postal Code
Phone
Home Phone
Work Phone
Mobile Phone
Fax
E-mail 
Relationship to premises
q Secondary Emergency Contact
q Landowner
(select all that apply)
q Primary Emergency Contact
q Other-Specify 
2. Premises Location
Property Identification Number or Assessment Number:
(can be found on your property tax bill)
Premises Identification (PID) Number:
Please complete this if a PID has already been assigned to this property
N
S
and you are updating any information related to this existing PID.
Civic Address
Annapolis
City/Town/Community
County
Location
Latitude (if available)
Longitude (if available)
Location Referenced by Coordinates (e.g. driveway, yard, barn, etc.)
Name or Description of Premises (Farm name if applicable)
List any additional property identification numbers for locations used solely for pasturing animals
www.novascotia.ca/agri/
Page 2 of 4 Rev 08Dec2016
3. Premises Types
 (indicate all applicable)
q Abattoir - Federal
q Rendering Facility
q Exhibition/Fairground
q Abattoir - Provincial
q Research Facility
q Farm
q Assembly Yard
q Stable/Horse Boarding Facility
q Feedlot
q Auction Market/Livestock Sales Facility q Hobby Farm/Small Acreage q Veterinary Clinic/Hospital/Lab
q Carcass/Deadstock Disposal Site
q Insemination Unit
(specify)
q Other
q Community Pasture
q Pasture
q Competition Facility
q Petting Farm/Zoo
q Embryo Transfer Facility
q Racetrack
4. Species
 (indicate all applicable)
Maximum capacity is the estimate of the highest number of a given species that this premises could
reasonably accommodate. Maximum capacity is not the number of animal currently on the premises.
If updating maximum capacity information or adding a species, please record the updated information and
the most current maximum capacity below.
Maximum
Maximum
Species Type
Species Type
Capacity
Capacity
q Laying Chickens
q Bison
q Broiler Chickens
q Llamas, Alpacas, Vicuna
q Cattle: Beef
q Pigs
q Cattle: Dairy
q Purebred/Fancier Flock
q Cervids (Deer, Elk)
q Sheep
q Farmed Rabbits
q Turkeys
q Wild Boar
q Goats
q Horses (ponies), donkeys, mules
Maximum
Other Species
Type
Capacity
q Birds -
Specify
q Wildlife (farmed, zoo)-
Specify
q Other -
Specify
www.novascotia.ca/agri/
Page 3 of 4 Rev 08Dec2016
5. Consent to Disclose Personal Information
Province of Nova Scotia Freedom of Information and Protection of Privacy Act, S.N.S. 1993, c. 5, Clause 26(b)
I,
, do hereby give consent to the Nova Scotia Department
of Agriculture to collect, use and disclose information, including my personal information contained in my
Premises Identification Program Application Form and any updated information thereof* to the Canadian
Food Inspection Agency, the Chief Veterinary Officer of Canada, Canadian Provincial Chief Veterinary Officers,
Government of Nova Scotia and foreign governments, as necessary, to be used for the purposes related to
the livestock traceability, including, preventing, preparing for, responding to or recovering from federally and
provincially-reportable animal diseases, diseases of significance to animal or public health, natural disaster
emergencies and other disasters involving livestock; or to verify the accuracy of information held in the Nova
Scotia Premises Identification Program.
*I will provide the necessary updates within 30 days of any change to ensure that the information related to the
premises in this Application Form and attached schedules is complete and correct.
Print full name of consenting individual
Signatue of consenting individual
Date (yyyy-mm-dd)
Provide the following contact information if not provided elsewhere on this form.
Mailing Address of Consenting Individual
Street/Apartment No./R.R. No.
Community/county
Postal code
Telephone Number of consenting individual (Residence and Business)
E-mail address of consenting individual
Return completed forms to: Nova Scotia Department of Agriculture
Agriculture and Food Operations – Agriculture Protection
Attn: Premises Identification Program
P.O. Box 890, Harlow Institute, Truro, NS, B2N 5G6
Questions?
Call: 902-890-9840
Fax: (902) 893-0244
Email:
NSPID@novascotia.ca
www.novascotia.ca/agri/
Page 4 of 4 Rev 08Dec2016
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