Form DMC163 "Application and Notification for Article 4 License" - New York

What Is Form DMC163?

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 November 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 DMC163 by clicking the link below or browse more documents and templates provided by the New York State Department of Agriculture and Markets.

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Download Form DMC163 "Application and Notification for Article 4 License" - New York

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Amendment __________
State of New York
(rev 11/17
DMC 163
)
Department of Agriculture and Markets
Division of Milk Control and Dairy Services
10B
Airline Drive
Albany, New York 12235
Application and Notification for Article 4 License
Name _____________________________________________ Telephone No. ___________________________
Street Address ____________________________ City__________________State_______ Zip____________
Social Security# ______________________ Federal ID# ___________________________________________
Reason for not providing SS# or Fed ID# (*See instructions on back of form)_______________________________________________________
Do you hold a NYS Milk Receiver's License? _______ If yes, ID # __________ Exp. Date ________________
Do you hold a NYS Bacterial License? ________ If yes, ID # ______________Exp. Date ________________
Present employer where license is required ______________________________________________________
Employer's Address _________________________________________________________________________
Applicant Email Address _____________________________________________________________________
Type of License(s) Requested
Milk Receivers:
Tester's License:
Drug Residue Test Methods:
 A. Farm Sampler
 I. Babcock
 2. Charm II
 B. CMl
 J. Gerber
 26. Charm SL-BL
 C. Laboratory Worker
 K. Ether Extraction – Mojonnier
 29. Charm II Sulfa
 D. Plant Worker
 L. Electronic Method
 30. Charm II Tetra
 E. Other
 M. Kjedahl
 31. Charm SL-3
 N. Total Solids
 33. Charm SL-6
 34. Charm Flunixin & Beta-lactam
Bacteria Counts:
 11. Standard Plate Count
 3. Delvo Test P
Phosphatase Test Methods:
 12. Direct Microscopic Count
 18. Scharer
 7. Snap Test
 13. Plate Loop Count
 20. Flourophos
 8. Disc Assay Method
 14. Petrifilm
 21.Charm
 10. HPLC
 27. Foss Bactoscan
 32. Beta Star
Somatic Cell Count Methods:
Water Coliform Test Methods:
 15. Direct Microscopic Somatic Cell Count
 22. Most Probable Number
 16. Foss – Optical Somatic Cell Count
 23. Membrane Filter
 17. Bentley – Optical Somatic Cell Count
 24. Chromogenic Substrate (P/A)
 25. Chromogenic (MPN)
At what location would you like to take the exam?____________________________________________________
I have read Sections 56, 56a and 57 of Article 4 of the Agriculture and Markets Law and Rules and Regulations for the sampling, weighing and testing of milk and other dairy
products for components, standards, and adulteration. I fully understand the meaning of these Sections of the law and the supplementary Rules and Regulations.
Signature of Applicant ______________________________________________ Date ________________________
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Report of Examination
Passed: Written _________ Practical_________
Failed: Written _________ Practical__________
Reason for Failure of Practical Exam_____________________________________________________________
(Applicant must pass written exam to take practical exam)
Dairy Products Specialist's Signature _______________________ID# ______Examination Date __________
MILK RECEIVER'S EXAM REQUIRES A 227B AND MUST BE ATTACHED TO THE APPLICATION.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
For Office Use Only
Type of License(s) Issued _____________________________ Date:_______________ ID # ___________________ Expires ______________ Area ___________
Amendment __________
State of New York
(rev 11/17
DMC 163
)
Department of Agriculture and Markets
Division of Milk Control and Dairy Services
10B
Airline Drive
Albany, New York 12235
Application and Notification for Article 4 License
Name _____________________________________________ Telephone No. ___________________________
Street Address ____________________________ City__________________State_______ Zip____________
Social Security# ______________________ Federal ID# ___________________________________________
Reason for not providing SS# or Fed ID# (*See instructions on back of form)_______________________________________________________
Do you hold a NYS Milk Receiver's License? _______ If yes, ID # __________ Exp. Date ________________
Do you hold a NYS Bacterial License? ________ If yes, ID # ______________Exp. Date ________________
Present employer where license is required ______________________________________________________
Employer's Address _________________________________________________________________________
Applicant Email Address _____________________________________________________________________
Type of License(s) Requested
Milk Receivers:
Tester's License:
Drug Residue Test Methods:
 A. Farm Sampler
 I. Babcock
 2. Charm II
 B. CMl
 J. Gerber
 26. Charm SL-BL
 C. Laboratory Worker
 K. Ether Extraction – Mojonnier
 29. Charm II Sulfa
 D. Plant Worker
 L. Electronic Method
 30. Charm II Tetra
 E. Other
 M. Kjedahl
 31. Charm SL-3
 N. Total Solids
 33. Charm SL-6
 34. Charm Flunixin & Beta-lactam
Bacteria Counts:
 11. Standard Plate Count
 3. Delvo Test P
Phosphatase Test Methods:
 12. Direct Microscopic Count
 18. Scharer
 7. Snap Test
 13. Plate Loop Count
 20. Flourophos
 8. Disc Assay Method
 14. Petrifilm
 21.Charm
 10. HPLC
 27. Foss Bactoscan
 32. Beta Star
Somatic Cell Count Methods:
Water Coliform Test Methods:
 15. Direct Microscopic Somatic Cell Count
 22. Most Probable Number
 16. Foss – Optical Somatic Cell Count
 23. Membrane Filter
 17. Bentley – Optical Somatic Cell Count
 24. Chromogenic Substrate (P/A)
 25. Chromogenic (MPN)
At what location would you like to take the exam?____________________________________________________
I have read Sections 56, 56a and 57 of Article 4 of the Agriculture and Markets Law and Rules and Regulations for the sampling, weighing and testing of milk and other dairy
products for components, standards, and adulteration. I fully understand the meaning of these Sections of the law and the supplementary Rules and Regulations.
Signature of Applicant ______________________________________________ Date ________________________
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
Report of Examination
Passed: Written _________ Practical_________
Failed: Written _________ Practical__________
Reason for Failure of Practical Exam_____________________________________________________________
(Applicant must pass written exam to take practical exam)
Dairy Products Specialist's Signature _______________________ID# ______Examination Date __________
MILK RECEIVER'S EXAM REQUIRES A 227B AND MUST BE ATTACHED TO THE APPLICATION.
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
For Office Use Only
Type of License(s) Issued _____________________________ Date:_______________ ID # ___________________ Expires ______________ Area ___________
* The authority to request the information contained in this document is found in Section 16 of
the Agriculture and Markets Law and the specific section or sections of that Law which relate to
the license, permit, certificate, approval, registration or permission which you seek. The
principal purpose for which this information is collected is to enable the Department of
Agriculture and Markets to determine whether or not to issue the requested license, permit,
certificate, approval, registration or permission. This information will be used by the
Department of Agriculture and Markets for the purpose of evaluating your application and
enforcing and administering the Agriculture and Markets Law.
Disclosure of your federal social security and federal employer identification numbers by you is
mandatory and is authorized by Section 5 of the Tax Law. The principal purpose for which this
information is collected is to enable the Department of Tax and Finance to identify individuals,
businesses and others who have been delinquent in filing tax returns or may have understated
their tax liabilities and to generally identify persons affected by the Tax Law administered by
the Commissioner of Taxation and Finance for administering the Tax Law and for any other
purpose authorized by the Tax Law.
Should you fail to provide all of the requested information, your application may not be
processed.
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