Form SFN12124 "Application for Wholesale Potato Dealer's License in North Dakota" - North Dakota

What Is Form SFN12124?

This is a legal form that was released by the North Dakota State Seed Department - a government authority operating within North Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2018;
  • The latest edition provided by the North Dakota State Seed Department;
  • 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 fillable version of Form SFN12124 by clicking the link below or browse more documents and templates provided by the North Dakota State Seed Department.

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Download Form SFN12124 "Application for Wholesale Potato Dealer's License in North Dakota" - North Dakota

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APPLICATION FOR WHOLESALE POTATO DEALER’S
LICENSE IN NORTH DAKOTA
PO Box 5257
NORTH DAKOTA STATE SEED DEPARTMENT
Fargo ND 58105
 
Phone: 701-231-5400
SFN 12124 (5-2018)
Fax:
701-231-5401
The undersigned hereby makes the following statement for the purpose of obtaining a license to conduct in
North Dakota the business of a wholesale potato dealer, as defined in Section 4.1-57 North Dakota Century
Code.
Give full name or exact trade name as preferred for listing
Name
Address
City
State
ZIP Code
Telephone Number
E-mail Address
:
If a co-partnership, give names of all individuals composing same
Name
Address
City
State
ZIP Code
Name
Address
City
State
ZIP Code
If a corporation, give names of officers and directors
President
Address
City
State
ZIP Code
Vice President
Address
City
State
ZIP Code
Secretary
Address
City
State
ZIP Code
Treasurer
Address
City
State
ZIP Code
General Manager/Director
Address
City
State
ZIP Code
Director
Adress
City
State
ZIP Code
APPLICATION FOR WHOLESALE POTATO DEALER’S
LICENSE IN NORTH DAKOTA
PO Box 5257
NORTH DAKOTA STATE SEED DEPARTMENT
Fargo ND 58105
 
Phone: 701-231-5400
SFN 12124 (5-2018)
Fax:
701-231-5401
The undersigned hereby makes the following statement for the purpose of obtaining a license to conduct in
North Dakota the business of a wholesale potato dealer, as defined in Section 4.1-57 North Dakota Century
Code.
Give full name or exact trade name as preferred for listing
Name
Address
City
State
ZIP Code
Telephone Number
E-mail Address
:
If a co-partnership, give names of all individuals composing same
Name
Address
City
State
ZIP Code
Name
Address
City
State
ZIP Code
If a corporation, give names of officers and directors
President
Address
City
State
ZIP Code
Vice President
Address
City
State
ZIP Code
Secretary
Address
City
State
ZIP Code
Treasurer
Address
City
State
ZIP Code
General Manager/Director
Address
City
State
ZIP Code
Director
Adress
City
State
ZIP Code
APPLICATION FOR WHOLESALE POTATO DEALER’S
LICENSE IN NORTH DAKOTA
PO Box 5257
NORTH DAKOTA STATE SEED DEPARTMENT
Fargo ND 58105
 
Phone: 701-231-5400
SFN 12124 (5-2018)
Fax:
701-231-5401
If a corporation,
State Incorporated
Date Incorporated
Address of principal office
Address
City
State
ZIP Code
Authorized capital
Capital subscribed for
Capital Paid in Cash
Location of office handling North Dakota business
Address
City
State
ZIP Code
Party in charge of North Dakota business
Name
Address
City
State
ZIP Code
Estimated largest quantity of potatoes bought or handled in this state in any one month:
Hundred Weight (CWT)
Dollar Amount
Total quantity of potatoes bought or handled in this state last year:
Hundred Weight (CWT)
Dollar Amount
APPLICATION FOR WHOLESALE POTATO DEALER’S
LICENSE IN NORTH DAKOTA
PO Box 5257
NORTH DAKOTA STATE SEED DEPARTMENT
Fargo ND 58105
 
Phone: 701-231-5400
SFN 12124 (5-2018)
Fax:
701-231-5401
Date
Statement of Applicant’s assets and liabilities or enclosed financial statement as of
Assets
Liabilities
Cash on hand not deposited in
Capital Stock paid (if any)
bank
Cash deposited in banks (state
Borrowed money (if none, write
names.)
“none”) Mortgages or other
obligations due on Real Estate (if
none, write none)
Real Estate, consisting of:
Due on Stocks & Bonds (if none,
write “None”
In whose name is title to real
Homestead Exemptions
estate?
Bills Payable (if none, write “None”
Stocks & Bonds (market value)
Accounts Payable
Merchandise on hand , in storage,
Other liabilities, list in detail
rolling or otherwise (cash value)
(if none, write “None”
Bills Receivable
Accounts Receivable
Other Assets (describe in detail)
TOTAL ASSETS
TOTAL LIABILITIES
Is the applicant (or applicants) a surety or an endorser upon any bond, note or other obligation not included in
the liabilities shown above?
Yes
No
Explain
To what extent do you grow or contract growing potatoes?
Are there any judgements against you?
Yes
No
Explain
APPLICATION FOR WHOLESALE POTATO DEALER’S
LICENSE IN NORTH DAKOTA
PO Box 5257
NORTH DAKOTA STATE SEED DEPARTMENT
Fargo ND 58105
 
Phone: 701-231-5400
SFN 12124 (5-2018)
Fax:
701-231-5401
Are you threatened with any lawsuits?
Yes
No
Is any suit, action or proceeding pending against applicant (or applicants) or either of any of them, which
directly or indirectly relates to potatoes purchased or received on consignment by the applicant?
Yes
No
If yes, provide plaintiff’s name and address and nature of such action:
Does applicant (or applicants) have similar license (covering potatoes or other produce)
Name of State
in any other states?
Yes
No
Has any individual or party to this application ever had a similar license (covering potatoes or other products)
refused, canceled or suspended or revoked in any other state?
Yes
No
Name places and dates if any
Have you ever received or accepted any potatoes from North Dakota or elsewhere for which the seller or
consignor has not been paid?
Yes
No
Name places, names and dates if any
Actual or approximate number of points in North Dakota where licensee will be operating a branch house and
need duplicate license
(Make application for these, and list them individually on our form No. 41)
Are you familiar with provisions of the Dealer’s Licensing Act (Chapter 4.1-57, North Dakota Century Code) and
the Labeling and Inspection Requirements (Chapter 4-.1-55, North Dakota Century Code)?
Yes
No
Do you agree to conduct your business in accordance with the above named acts (in No. 22) and the official
regulations in force thereunder?
Yes
No
References as to record, character and business standing of the applicant (or applicants)
Name
Business
City
State
APPLICATION FOR WHOLESALE POTATO DEALER’S
LICENSE IN NORTH DAKOTA
PO Box 5257
NORTH DAKOTA STATE SEED DEPARTMENT
Fargo ND 58105
 
Phone: 701-231-5400
SFN 12124 (5-2018)
Fax:
701-231-5401
SIGN AND ACKNOWLEDGE ON NEXT PAGE
(Individual, Firm, or Corporation Name)
Dated at
this
day of
20__
By
(Signature and Title of Individual Representing Applicant)
Corporate Seal
Each additional co-partnership member must
sign here:
Affix
Acknowledgment
State of
County of
On this
day of
, 20__, before me personally appeared
to me personally known and known to me to be the individual described in and who executed the foregoing
instrument, by me being duly sworn depose
and say
that
he
is a (are) member
or an officer as above designated with
signature
, of
the firm or corporation named in the foregoing application, and that all the statements made therein were
reviewed by
and are true and correct in every respect to the best of
knowledge.
Subscribed and sworn before me this
day of
, 20__.
Notary Public
Do not neglect to supply the $200.00 license fee. The fee for duplicate licenses is $1.00.
License No.
Application No.
APPLICATION FOR
POTATO DEALER’S LICENSE
Date Application Received
Amount of Bond
Name of Surety
Bond Executed
Date Approved
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