"New Brunswick Livestock Premises Identification Application" - New Brunswick, Canada

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RESET FORM
NEW BRUNSWICK LIVESTOCK PREMISES IDENTIFICATION APPLICATION
This form may be used to apply for a Livestock Premises Identification (LPID) number or to update information related to an
existing Livestock Premises Identification number.
To apply for a new LPID, 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 LPID, please complete all information areas that have been modified and sign the
consent to disclose information area at the end of the form.
You will require your Property Identification Number from Service New Brunswick
http://www.snb.ca/e/0001e.asp
or from your property tax form.
More information can be found at
http://www2.gnb.ca/content/gnb/en/departments/10/services/services_renderer.201363.Register_Animal_Premises
for_Livestock_and_Poultry_Traceability.html
Purpose of Application
New Applicant
Update my file- Please provide your Livestock Premises Identification Number
NB
1.0 Business Contact Information
Business Name:
First Name:
Last Name:
Mailing Address:
Civic Number:
Street :
City/Town/Community:
Province :
Postal Code:
Home Phone:
Cell:
Work:
Fax:
E-mail:
2.0 Emergency Contacts
Primary Contact (if different from business contact)
First Name:
Last Name:
Mailing Address:
Civic Number:
Street :
City/Town/Community:
Province :
Postal Code:
Home Phone:
Cell:
Work:
Fax:
E-mail:
Secondary Emergency Contact (if different from business contact)
First Name:
Last Name:
Mailing Address:
Civic Number:
Street :
City/Town/Community:
Province :
Postal Code:
Home Phone:
Cell:
Work:
Fax:
E-mail:
Version 4.1 (Revised September 2018)
Livestock Premises Identification Application
Page 1 of 4
PRINT
RESET FORM
NEW BRUNSWICK LIVESTOCK PREMISES IDENTIFICATION APPLICATION
This form may be used to apply for a Livestock Premises Identification (LPID) number or to update information related to an
existing Livestock Premises Identification number.
To apply for a new LPID, 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 LPID, please complete all information areas that have been modified and sign the
consent to disclose information area at the end of the form.
You will require your Property Identification Number from Service New Brunswick
http://www.snb.ca/e/0001e.asp
or from your property tax form.
More information can be found at
http://www2.gnb.ca/content/gnb/en/departments/10/services/services_renderer.201363.Register_Animal_Premises
for_Livestock_and_Poultry_Traceability.html
Purpose of Application
New Applicant
Update my file- Please provide your Livestock Premises Identification Number
NB
1.0 Business Contact Information
Business Name:
First Name:
Last Name:
Mailing Address:
Civic Number:
Street :
City/Town/Community:
Province :
Postal Code:
Home Phone:
Cell:
Work:
Fax:
E-mail:
2.0 Emergency Contacts
Primary Contact (if different from business contact)
First Name:
Last Name:
Mailing Address:
Civic Number:
Street :
City/Town/Community:
Province :
Postal Code:
Home Phone:
Cell:
Work:
Fax:
E-mail:
Secondary Emergency Contact (if different from business contact)
First Name:
Last Name:
Mailing Address:
Civic Number:
Street :
City/Town/Community:
Province :
Postal Code:
Home Phone:
Cell:
Work:
Fax:
E-mail:
Version 4.1 (Revised September 2018)
Livestock Premises Identification Application
Page 1 of 4
NEW BRUNSWICK LIVESTOCK PREMISES IDENTIFICATION APPLICATION
3.0 Livestock Premises Location
Premises - SNB Property Identification Number Required
(From property tax form or SNB website
http://www.snb.ca/e/0001e.asp
Civic Address of Premises:
Civic Number:
Street :
City/Town/Community:
Province :
Postal Code:
Location (Landmark) i.e. Church, bridge
4.0 Sub-Premises Location #1 ie: additional location for animals or barns
Sub-Premises - SNB Property Identification Number Required

(From property tax form)
Civic Address of Sub-Premises:
Civic Number:
Street :
City/Town/Community:
Province :
Postal Code:
Location (Landmark) i.e. Church, bridge
4.01 Sub-Premises Location #2
Sub-Premises - SNB Property Identification Number Required
(From property tax form)
Civic Address of Sub-Premises:
Civic Number:
Street :
City/Town/Community:
Province :
Postal Code:
Location (Landmark) i.e. Church, bridge
5.0 Parcel Owner
(if different from business contact)
Business Name:
First Name:
Last Name:
Mailing Address:
Civic Number:
Street :
City/Town/Community:
Province :
Postal Code:
Home Phone:
Cell:
Work:
NOTE:
Attach additional applications if applying for more than one premises and/or more than 2 sub-premises. On
additional applications, the information from section 1.0 (Business Contact Information), section 2.0 (Emergency
Contacts) and section 5.0 (Parcel Owner) does not need to be supplied unless the information differs from the
information supplied on the original application.
Version 4.1 (Revised September 2018)
Livestock Premises Identification Application
Page 2 of 4
NEW BRUNSWICK LIVESTOCK PREMISES IDENTIFICATION APPLICATION
6.0 Livestock Premises Type (Check all applicable premises type)
Farm
Feedlot
Assembly Yard
Hatchery
Pasture
Boarding Stable
Egg Grading/Processing
Poultry Processing Plant
Abattoir
Rendering Plant
Research Facility
Insemination Center
Exhibition/Fair-Grounds
Veterinary Facility
Other - Specify:
Zoo, Petting Zoo
Auction Livestock Sale Facility
Race Track
__________________________
Community Pasture
7.0 Species Type (Check type of Species)
Cattle: Beef
Pigs
Cervids (Deer, Elk)
Farmed fur- Fox
Cattle: Dairy
Sheep
Farmed Rabbits
Farmed fur- Mink
Broiler Chickens
Goats
Wild Boar
Purebred/Fancier Flock
Laying Hens
Turkeys
Bison
Horses (Ponies), Donkeys, Mules
Layer Breeder
Broiler Breeder
Other Species:
Birds - Specify: ________________________________________________________
Wildlife (Farmed, Zoo) - Specify: __________________________________________
Other - Specify: ________________________________________________________
Version 4.1 (Revised September 2018)
Livestock Premises Identification Application
Page 3 of 4
NEW BRUNSWICK LIVESTOCK PREMISES IDENTIFICATION APPLICATION
8.0 Consent to Use and Disclosure of Personal Information and Livestock Premises Information
I, ________________________________ , do hereby give consent to the New Brunswick Department of Agriculture,
Aquaculture and Fisheries to collect personal information and livestock premises information on this form for the purposes
described below.
The personal information collected on this application form is being collected for the Premises Identification Program of the New
Brunswick Department of Agriculture, Aquaculture and Fisheries and will be used for one or more of the following purposes:
(a) detecting, preventing, controlling, managing and eliminating disease;
(b) analyzing the geographical distribution of disease and the epidemiology of disease outbreaks;
(c) conducting assessments and models to prevent disease risk;
(d) tracking the movement of animals from premises to premises;
(e) protecting animal health and human health;
(f) emergency planning;
(g) eliminating disease barriers to market access;
(h) verifying the accuracy of information collected on the application form.
The information may be released to the following persons or entities:
(a) a department, branch, office or agency of the government of New Brunswick;
(b) the Government of Canada or a municipal, provincial or foreign government or an agency of such a government, including
employees thereof whose duties include:
i. protecting the public health
ii. monitoring or reporting on the safety of agricultural inputs, foods, livestock or livestock products, or
iii. monitoring or reporting on the biological, chemical and physical integrity of agricultural inputs, food, livestock or
livestock products;
(c) the following producer board(s) / agencies:
NB Cattle Producers
Turkey Farmers of NB
Porc NB Pork
NB Egg Producers
Chicken Farmers of NB
Dairy Farmers of NB
Other:
Canadian Cattle Identification Agency (CCIA)
(d) as required by law.
(Print Name)
(Signature)
(Date)
Disclosure of personal information is governed by the Protection of Privacy provisions of The Right to Information and Protection of
Privacy Act. If you have any questions about the collection of personal information contact the New Brunswick Department of
Agriculture, Aquaculture and Fisheries. Mail or fax your completed application to the address below or complete online, print, sign,
scan and return electronically to:
Livestock Premises Identification
NB Dept. of Agriculture, Aquaculture and Fisheries
PO Box 6000, Fredericton, NB E3B 5H1
Phone: 506-453-2109
Fax: 506-453-7978
Email: DAAF-MAAP@gnb.ca
Version 4.1 (Revised September 2018)
Livestock Premises Identification Application
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