Form FSI-417 "Application for Feed Manufacturing License - Article 8" - New York

What Is Form FSI-417?

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 FSI-417 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 FSI-417 "Application for Feed Manufacturing License - Article 8" - New York

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FSI-417 (1/17)
APPLICATION FOR FEED MANUFACTURING LICENSE – ARTICLE 8
NYS Department of Agriculture and Markets
Attn: Food Safety Feed Unit
10B Airline Drive, Albany, New York 12235
Office Use Only
County Code- Est. No.
Entity No.__________________________
NO LICENSE FEE REQUIRED
APPLICATION MUST BE FULLY COMPLETED
ompletion and submission of this form does
C
not constitute authorization to operate a feed
manufacturing establishment.
Section (7) requires an original signature of
owner or corporate officer.
Please Print or Type All Requested Information:
(1) Individual Owner Name, Partnership or Full Name of the Corporation:
County:
Trade Name:
Business Telephone Number:
(
)
Street:
City:
State:
Zip:
E-mail Address:
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-417 (1/17)
APPLICATION FOR FEED MANUFACTURING LICENSE – ARTICLE 8
NYS Department of Agriculture and Markets
Attn: Food Safety Feed Unit
10B Airline Drive, Albany, New York 12235
Office Use Only
County Code- Est. No.
Entity No.__________________________
NO LICENSE FEE REQUIRED
APPLICATION MUST BE FULLY COMPLETED
ompletion and submission of this form does
C
not constitute authorization to operate a feed
manufacturing establishment.
Section (7) requires an original signature of
owner or corporate officer.
Please Print or Type All Requested Information:
(1) Individual Owner Name, Partnership or Full Name of the Corporation:
County:
Trade Name:
Business Telephone Number:
(
)
Street:
City:
State:
Zip:
E-mail Address:
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)
(5) Check all that apply for this license:
Non-Medicated Feed Mfg. Submit labels with application
Medicated Feed Mfg. Submit labels with application
Customer Formula Feed Mfg.
(6) Workers Compensation Law requires that businesses seeking state issued permits demonstrate that they have appropriate
Workers Compensation Insurance (WCI). Indicate your WCI status:
Insured with _________________________________________
Self Insured
Exempt from WCI
Name of Insurance Provider
The undersigned applies for a license pursuant to Article 8 of the Agriculture and Markets Law of the State of New York to conduct the
feed manufacturing operations listed above, at this location only. In support of this application, the undersigned makes the above
statements and agrees to comply with the requirements of Article 8.
Any false statements made herein, 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.
Signature Required
(7) ORIGINAL 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.
All fields must be completed. Incomplete applications may not be processed. If you have questions
about the information requested, call (518) 457-5457; e-mail agr.sm.foodlicense@agriculture.ny.gov;
or write to: Department of Agriculture and Markets; Attn: Food Safety Feed Unit, 10B Airline Drive;
Albany, NY 12235.
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