"Application for License to Sell a Brand of Agricultural Soil or Plant Inoculant" - New York

Application for License to Sell a Brand of Agricultural Soil or Plant Inoculant is a legal document that was released by the New York State Department of Agriculture and Markets - a government authority operating within New York.

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APPLICATION FOR
FOR OFFICE USE ONLY
LICENSE TO SELL A BRAND OF
Est. No.:
_
___
___
___
___
AGRICULTURAL
License No.:
SOIL OR PLANT INOCULANT
Product No.:
Date Approved:
Division of Plant Industry
For the period ending
10B Airline Drive
Reviewed:
Approved:
Albany, NY 12235
_________________
Phone No. (518) 453-8130
www.agriculture.ny.gov
No fee for this license
1a. Business Name(If business type is individual, must be persons
1b. Phone No. (
)
name)
Fax No.
(
)
1c. Email:
2. Business Location Address
City
State
Zip Code
3. Business Mailing Address ( if different from above)
City
State
Zip Code
4. Contact person to receive mailings. Include mailing and/or business address if different from above (add additional sheets if necessary)
Contact Type
Name
Business Name
Address
(select one or more)
Applications
Licenses
Applications
Licenses
5a. Check Business Type:
5b. State Incorporated and Date
INDIVIDUAL
LIMITED PARTNERSHIP
5c. Federal ID # or SS # (if individual)*
CORPORATION
GENERAL PARTNERSHIP
5d. If no SSN or FEIN please indicate reason:
COOPERATIVE
LIMITED LIABILITY COMPANY (LLC)
6. Individual owners, Members of Partnership, Officers of Corporation, Cooperative or Members of LLC must answer the following. Attach
list if necessary:
Name
Title
Home Address
7. Have you or an officer, director or any stockholder exercising any position of management or control been convicted of a felony
and/or misdemeanor in any court of the U.S. or any state or territory?
Yes
No
If yes, please explain:
8. Are you a foreign or out of state individual, partnership of corporation?
Yes
No
Date of Filing with NYS Department of State (if applicable)
By checking the box above, a foreign or out of state individual, partnership or corporation consents to personal jurisdiction in the courts
of New York State in any action which may be brought by the New York State Department of Agriculture and Markets for matters
relating to the requested license. The applicant also agrees to accept service of process in any such action by service of a summons
and/or complaint by first class mail to the designated individual at the said address below which shall constitute good and proper
service of process.
Designated Individual:
at address
THIS APPLICATION REQUIRES A SIGNATURE ON THE BACK TO BE PROCESSED
APPLICATION FOR
FOR OFFICE USE ONLY
LICENSE TO SELL A BRAND OF
Est. No.:
_
___
___
___
___
AGRICULTURAL
License No.:
SOIL OR PLANT INOCULANT
Product No.:
Date Approved:
Division of Plant Industry
For the period ending
10B Airline Drive
Reviewed:
Approved:
Albany, NY 12235
_________________
Phone No. (518) 453-8130
www.agriculture.ny.gov
No fee for this license
1a. Business Name(If business type is individual, must be persons
1b. Phone No. (
)
name)
Fax No.
(
)
1c. Email:
2. Business Location Address
City
State
Zip Code
3. Business Mailing Address ( if different from above)
City
State
Zip Code
4. Contact person to receive mailings. Include mailing and/or business address if different from above (add additional sheets if necessary)
Contact Type
Name
Business Name
Address
(select one or more)
Applications
Licenses
Applications
Licenses
5a. Check Business Type:
5b. State Incorporated and Date
INDIVIDUAL
LIMITED PARTNERSHIP
5c. Federal ID # or SS # (if individual)*
CORPORATION
GENERAL PARTNERSHIP
5d. If no SSN or FEIN please indicate reason:
COOPERATIVE
LIMITED LIABILITY COMPANY (LLC)
6. Individual owners, Members of Partnership, Officers of Corporation, Cooperative or Members of LLC must answer the following. Attach
list if necessary:
Name
Title
Home Address
7. Have you or an officer, director or any stockholder exercising any position of management or control been convicted of a felony
and/or misdemeanor in any court of the U.S. or any state or territory?
Yes
No
If yes, please explain:
8. Are you a foreign or out of state individual, partnership of corporation?
Yes
No
Date of Filing with NYS Department of State (if applicable)
By checking the box above, a foreign or out of state individual, partnership or corporation consents to personal jurisdiction in the courts
of New York State in any action which may be brought by the New York State Department of Agriculture and Markets for matters
relating to the requested license. The applicant also agrees to accept service of process in any such action by service of a summons
and/or complaint by first class mail to the designated individual at the said address below which shall constitute good and proper
service of process.
Designated Individual:
at address
THIS APPLICATION REQUIRES A SIGNATURE ON THE BACK TO BE PROCESSED
Name of Product:
Is the product effective for inoculating legumes?:
Yes
No
If yes, which legume or legumes is so represented?
Is the product intended for some other purpose?
Guaranteed Analysis- List name of each ingredient
Active Ingredients
Percentage
%
%
%
Inert Ingredients
%
%
%
I (We) agree to permit free entry and free access to licensed premises, buildings, and offices to the Commissioner and his agents in
pursuance of the distribution, sale and use of soil or plant inoculants subject to the Commissioner’s jurisdiction.
Yes
I understand that the statements made in this application will be accepted for all purposes as the equivalent of an Affidavit and that
any false statements made herein, in addition to being the possible basis for a revocation of any license issued as a result of this
application, may be punishable as a misdemeanor under the provisions of Section 210.45 of the Penal law of the State of New
York.”
Individual, Firm or Corporate Name (See Note Below)
Date
Signature of Person Executing
Title
NOTE: (a) If the applicant is an individual doing business under his own name, he must sign on signature line; (b) if co-partnership or
assumed name, firm name must be given and one member must sign individually on signature line; (c) if corporation, corporate name
must be given in full, with an authorized officer’s signature on signature
line and title on title line.
*The authority to request the information contained in this document is found in Section16 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 principle 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 principle purpose for which this information is collected is 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 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 and a signature, your application will not be processed.
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