Form FSI1000 "Application for Transportation Service License - Article 5-c" - New York

What Is Form FSI1000?

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

Form Details:

  • Released on January 1, 2017;
  • The latest edition provided by the New York State Department of Agriculture and Markets;
  • 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 FSI1000 by clicking the link below or browse more documents and templates provided by the New York State Department of Agriculture and Markets.

ADVERTISEMENT
ADVERTISEMENT

Download Form FSI1000 "Application for Transportation Service License - Article 5-c" - New York

494 times
Rate (4.4 / 5) 35 votes
FSI 1000 (1/17)
APPLICATION FOR TRANSPORTATION SERVICE LICENSE – ARTICLE 5-C
NYS Department of Agriculture and Markets
Attn: Food Safety License Unit
10B Airline Drive, Albany, NY 12235
Office Use Only
County Code- Est. No.
Entity No. ______________________
NO LICENSE FEE REQUIRED
INSTRUCTIONS
Read and complete both sides of this application
If operator of more than one service, fill out an
additional application for each service.
An original signature of owner or corporate officer is
required in Section (6).
(1) Individual Owner Name, Partnership or Full Name of the Corporation:
County:
Trade Name:
Business Telephone Number:
(
)
Street:
City:
State:
Zip:
E-Mail:
Bank Name:
(2) Optional Mailing Address:
Street:
City:
State:
Zip:
(3) Identification Number:
Federal ID Number
OR
Social Security Number
(4) Please list sole proprietors and all officers of a corporation or cooperative. If applicant is a partnership, LLC, or LLP, list partners/members
(attach list if necessary). If applicant is a non-public corporation, list shareholders (attach list if necessary).
Title
Contact Address (Street & No., City, State, Zip)
Name (Please Print)
Date of Birth
E-Mail address
(4a.) Principal Office Address: ______________________________________________________________________________________________
(4b.) In what state incorporated? ________________________ (4c.) Date of Incorporation _____________________________________________
(4d.) Are you a foreign or out-of-New-York-state individual, partnership, or corporation? (Check One)
Yes
No
(4e.) For foreign or out-of-New-York-state corporations:
Date of filing in New York State? ____________________
(4f.) If out-of-New-York-state, the applicant agrees to accept service of process by first class mail to the designated individual at the said address below
which shall constitute good and proper service of process.
Designated:_____________________________________
Address: _______________________________________________________
(PLEASE COMPLETE REVERSE SIDE)
FSI 1000 (1/17)
APPLICATION FOR TRANSPORTATION SERVICE LICENSE – ARTICLE 5-C
NYS Department of Agriculture and Markets
Attn: Food Safety License Unit
10B Airline Drive, Albany, NY 12235
Office Use Only
County Code- Est. No.
Entity No. ______________________
NO LICENSE FEE REQUIRED
INSTRUCTIONS
Read and complete both sides of this application
If operator of more than one service, fill out an
additional application for each service.
An original signature of owner or corporate officer is
required in Section (6).
(1) Individual Owner Name, Partnership or Full Name of the Corporation:
County:
Trade Name:
Business Telephone Number:
(
)
Street:
City:
State:
Zip:
E-Mail:
Bank Name:
(2) Optional Mailing Address:
Street:
City:
State:
Zip:
(3) Identification Number:
Federal ID Number
OR
Social Security Number
(4) Please list sole proprietors and all officers of a corporation or cooperative. If applicant is a partnership, LLC, or LLP, list partners/members
(attach list if necessary). If applicant is a non-public corporation, list shareholders (attach list if necessary).
Title
Contact Address (Street & No., City, State, Zip)
Name (Please Print)
Date of Birth
E-Mail address
(4a.) Principal Office Address: ______________________________________________________________________________________________
(4b.) In what state incorporated? ________________________ (4c.) Date of Incorporation _____________________________________________
(4d.) Are you a foreign or out-of-New-York-state individual, partnership, or corporation? (Check One)
Yes
No
(4e.) For foreign or out-of-New-York-state corporations:
Date of filing in New York State? ____________________
(4f.) If out-of-New-York-state, the applicant agrees to accept service of process by first class mail to the designated individual at the said address below
which shall constitute good and proper service of process.
Designated:_____________________________________
Address: _______________________________________________________
(PLEASE COMPLETE REVERSE SIDE)
APPLICANTS MUST PROVIDE ALL REQUESTED INFORMATION
(5) VEHICLE IDENTIFICATION
(Vehicles used in Transportation Service)
YEAR AND MAKE
VEHICLE IDENTIFICATION NO.
LICENSE NO.
1._________________________________________________
___________________________________
____________________
2._________________________________________________
___________________________________
____________________
3._________________________________________________
___________________________________
____________________
4._________________________________________________
___________________________________
____________________
5._________________________________________________
___________________________________
____________________
6._________________________________________________
___________________________________
____________________
7._________________________________________________
___________________________________
____________________
8._________________________________________________
___________________________________
____________________
9._________________________________________________
___________________________________
____________________
10.________________________________________________
___________________________________
____________________
11.________________________________________________
___________________________________
____________________
12.________________________________________________
___________________________________
____________________
6) ORIGINAL SIGNATURE OF OWNER, PARTNER OR CORPORATE OFFICER TITLE DATE
The undersigned applies for a license to operate a Transportation Service and represents that the premises, physical facilities, and equipment to be
used by applicant and the operation thereof, comply with the requirements of Article 5-C of the Agriculture and Markets Law and Rules and Regulations
promulgated there under for the transport of inedible meat or bodies or carcasses of animals not intended for human consumption.
Applicant consents to free entry and will permit free access to licensed premises, buildings and offices to the Commissioner, the Commissioners agents,
and inspectors in pursuance of the Commissioner’s duty to supervise and regulate the production, storage, sale and use of articles subject to the
Commissioners jurisdiction.
Applicant understands the statements made in the application will be accepted, for all purposes, as the equivalent of an Affidavit.
Any false statements made, in addition to being the possible basis for a revocation on any license issued as a result of this application, may be
punishable under the provisions of Section 210.45 of the Penal Law of the State of New York.
NOTE: Your application for a license is subject to denial and/or revocation, if, after a hearing, it is determined that the applicant, licensee, officer,
director, partner or share/stockholder, has been convicted of, or has pled guilty to, a felony in any court of the United States or any State or territory
thereof, with respect to an offense involving; food safety, food adulteration or food misbranding.
Providing your signature below acknowledges your understanding of requirements listed herein and that you agree to comply with the requirements of
Article 5-C.
SIGNATURE OF OWNER, PARTNER OR CORPORATE OFFICER
TITLE
DATE
AUTHORIZATION AND PURPOSE
Disclosure of your federal social security and federal employer identification numbers is mandatory and is authorized by Section 5 of the New York State
Tax Law. This information is collected to enable the Department of Taxation and Finance to identify individuals, businesses and others who have been
delinquent in filing tax returns or may have understated their tax liability and to generally identify persons affected by the Tax Law administered by the
Commissioner of Taxation and Finance administering the Tax Law and for any other purpose authorized by the Tax Law. The authority to solicit the
information requested above is found in Section 16 of the Agriculture and Markets Law in the sections relating to the specific license you are seeking.
This information is collected to enable the Department to evaluate your application, to determine if it should be issued and to assist in the enforcement
and administration of the Agriculture and Markets Law.
If you have questions about the information requested, call (518) 457-7139; e-mail agr.sm.foodlicense@agriculture.ny.gov; or write to: NYS Department
of Agriculture and Markets; Attn: Food Safety License Unit; 10B Airline Drive; Albany, NY 12235.
Page of 2