Form IL406-0039 "Application for Illinois Egg License" - Illinois

What Is Form IL406-0039?

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

Form Details:

  • Released on January 1, 2019;
  • The latest edition provided by the Illinois Department of Agriculture;
  • 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 IL406-0039 by clicking the link below or browse more documents and templates provided by the Illinois Department of Agriculture.

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Download Form IL406-0039 "Application for Illinois Egg License" - Illinois

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Illinois Department of Agriculture
Food Safety and Animal Protection - Egg Inspection Program
P.O. Box 19281 Springfield, IL 62794-9281
217/524-1550 - Fax 217/524-7801 TDD/TTY: 866/287-2999
Website-www.agr.state.il.us – Egg email - AGR.Eggs@illinois.gov
THIS FORM SHOULD BE FILLED IN
APPLICATION FOR ILLINOIS EGG LICENSE
ON-LINE, SAVED, PRINTED AND MAILED
WITH YOUR PAYMENT TO THE ABOVE
ADDRESS.
ALL QUESTIONS AND SIGNATURES IN THIS APPLICATION MUST BE COMPLETED - IF NOT, YOUR APPLICATION WILL BE RETURNED
The licensing year for an egg license is July 1 through June 30. The egg license shall expire on June 30. Licenses not renewed by July 1 shall
be assessed a $50 penalty. The undersigned hereby makes application to the Illinois Department of Agriculture under the provisions of the
Illinois E and Egg Products Act, approved September 3, 1975, as amended. Remit license fees with this form to the address listed above.
Business Name to appear on license
License Number (if known)
Business Address (where eggs are located)
City
State,
Zip Code
County (Illinois State Only)
FEIN # or SSN#
Residence (Please
check if applicable)
Mailing Address (if different from business address)
City
State,
Zip Code
Business Telephone Number
Fax Number
Cell Phone Number
Contact Person
Contact Phone Number
Email Address
4. CLASSIFICATION OF LICENSES
NEW APPLICATION (including new ownership)
TYPE OF LICENSE REQUESTED (PLEASE CHECK ONE)
FOR ADDRESS CHANGES use the
Change of Address Form
ANNUAL RENEWAL APPLICATION (same ownership and
LIMITED LICENSE . . . . . . . . . . . . . . . . . Fee $15 .00
location as the previous year)
PRODUCER-DEALER - sells ONLY graded eggs produced by own flock.
REACTIVATE INACTIVE LICENSE (a location that has had a
TOTAL FLOCK(S) SIZE
license with us before, but was deactivated for a period of time)
FULL LICENSE . . . . . . . . . . . . . . . . . . . . Fee $50 .00
LICENSE DELIVERY
PRODUCER-DEALER - sells graded eggs produced by own flock AND
eggs from other producer-dealers.
Mail physical copy to my address
Email digital copy
TOTAL FLOCK SIZE
1. APPLICANT IS:
GRADING STATION - candles and grades nest run eggs without any
chickens on site
Association
Partnership
Corporation
SEE
JOBBER - a handler whose primary place of business is a truck or vehicle
LLC
Individual
Other
BACK
BROKER - transfers ownership of eggs or eggs products from one entity to
another without necessarily taking possession
2. PLEASE CIRCLE OR CHECK TYPE(S) OF EGGS BEING SOLD
DISTRIBUTOR - entity supplying eggs to stores or other businesses not
Chicken
Turkey
Duck*
Goose
Guinea
counting hauling only
*Salted/processed duck eggs do not require an IL Egg License
EGG BREAKERS LICENSE . . . . . . . . . . Fee $200 .00
3. HAS THERE BEEN A CHANGE IN OWNERSHIP AT THIS
LOCATION IN THE LAST 12 MONTHS?
A facility that breaks eggs and separates contents from the shell.
Yes
No
Please see 410 ILCS 615 and 8 IAC 65 for more detailed licensee definitions
IDOA USE ONLY: CC:
Check #
Amt:
Rev Code 411 412 413 415
IMPORTANT NOTICE: This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined
under Illinois Revised Statutes, Chapter 56 1/2, Paragraph 55-1 through 55-21. Failure to provide this information shall prevent this form from being
processed. This form has been approved by the State Forms Management Center. IL406-0039 (Rev. 2019)
Application for Illinois Egg License • Page 1 of 2
Illinois Department of Agriculture
Food Safety and Animal Protection - Egg Inspection Program
P.O. Box 19281 Springfield, IL 62794-9281
217/524-1550 - Fax 217/524-7801 TDD/TTY: 866/287-2999
Website-www.agr.state.il.us – Egg email - AGR.Eggs@illinois.gov
THIS FORM SHOULD BE FILLED IN
APPLICATION FOR ILLINOIS EGG LICENSE
ON-LINE, SAVED, PRINTED AND MAILED
WITH YOUR PAYMENT TO THE ABOVE
ADDRESS.
ALL QUESTIONS AND SIGNATURES IN THIS APPLICATION MUST BE COMPLETED - IF NOT, YOUR APPLICATION WILL BE RETURNED
The licensing year for an egg license is July 1 through June 30. The egg license shall expire on June 30. Licenses not renewed by July 1 shall
be assessed a $50 penalty. The undersigned hereby makes application to the Illinois Department of Agriculture under the provisions of the
Illinois E and Egg Products Act, approved September 3, 1975, as amended. Remit license fees with this form to the address listed above.
Business Name to appear on license
License Number (if known)
Business Address (where eggs are located)
City
State,
Zip Code
County (Illinois State Only)
FEIN # or SSN#
Residence (Please
check if applicable)
Mailing Address (if different from business address)
City
State,
Zip Code
Business Telephone Number
Fax Number
Cell Phone Number
Contact Person
Contact Phone Number
Email Address
4. CLASSIFICATION OF LICENSES
NEW APPLICATION (including new ownership)
TYPE OF LICENSE REQUESTED (PLEASE CHECK ONE)
FOR ADDRESS CHANGES use the
Change of Address Form
ANNUAL RENEWAL APPLICATION (same ownership and
LIMITED LICENSE . . . . . . . . . . . . . . . . . Fee $15 .00
location as the previous year)
PRODUCER-DEALER - sells ONLY graded eggs produced by own flock.
REACTIVATE INACTIVE LICENSE (a location that has had a
TOTAL FLOCK(S) SIZE
license with us before, but was deactivated for a period of time)
FULL LICENSE . . . . . . . . . . . . . . . . . . . . Fee $50 .00
LICENSE DELIVERY
PRODUCER-DEALER - sells graded eggs produced by own flock AND
eggs from other producer-dealers.
Mail physical copy to my address
Email digital copy
TOTAL FLOCK SIZE
1. APPLICANT IS:
GRADING STATION - candles and grades nest run eggs without any
chickens on site
Association
Partnership
Corporation
SEE
JOBBER - a handler whose primary place of business is a truck or vehicle
LLC
Individual
Other
BACK
BROKER - transfers ownership of eggs or eggs products from one entity to
another without necessarily taking possession
2. PLEASE CIRCLE OR CHECK TYPE(S) OF EGGS BEING SOLD
DISTRIBUTOR - entity supplying eggs to stores or other businesses not
Chicken
Turkey
Duck*
Goose
Guinea
counting hauling only
*Salted/processed duck eggs do not require an IL Egg License
EGG BREAKERS LICENSE . . . . . . . . . . Fee $200 .00
3. HAS THERE BEEN A CHANGE IN OWNERSHIP AT THIS
LOCATION IN THE LAST 12 MONTHS?
A facility that breaks eggs and separates contents from the shell.
Yes
No
Please see 410 ILCS 615 and 8 IAC 65 for more detailed licensee definitions
IDOA USE ONLY: CC:
Check #
Amt:
Rev Code 411 412 413 415
IMPORTANT NOTICE: This state agency is requesting disclosure of information that is necessary to accomplish the statutory purpose as outlined
under Illinois Revised Statutes, Chapter 56 1/2, Paragraph 55-1 through 55-21. Failure to provide this information shall prevent this form from being
processed. This form has been approved by the State Forms Management Center. IL406-0039 (Rev. 2019)
Application for Illinois Egg License • Page 1 of 2
5. INSPECTION FEE INFORMATION (Please check one) –
**Please note: If you are a new licensee, please enter zero on the question below regarding cases sold unless
you are able to provide documentation otherwise from the previous calendar year. Program staff will work with
new applicants to determine whether you will be on quarterly or annual inspection fee reporting .
 Producers-Dealers – How many 30 dozen cases did you sell in IL during the previous calendar year?
 Distributors/Brokers/Jobbers/Grading Stations –
Name of business providing eggs (who is supplying eggs to you?) __________________________________________
Is the business you purchase eggs from licensed to do business in Illinois?
YES ___ NO___ DON’T KNOW___
If you are an out-of-state distributor, how many 30 dozen cases did you sell in IL during the previous calendar year?
*An inspection fee of 11 cents per 30 dozen case is assessed on all candled and graded eggs sold in Illinois. The
firsthandler in Illinois who packed and sold the eggs shall pay the prescribed inspection fee. In the event that the eggs
are shipped into Illinois, the handler who invoiced the eggs to Illinois shall pay the fee. Inspection fees shall be paid on
a quarterly basis, except those persons selling less than 600 cases of eggs per year will be paying annually. Please
do NOT include inspection fees with this application – you will receive the inspection fee report in a separate
mailing either on a quarterly or annual basis based on your response above .
*Please enclose a current copy of the invoice from the business you purchase your eggs from with your
license application or renewal .
6. CERTIFICATIONS: Failure to check one of the boxes below and sign the application may result in
The Department refusing to process your application:
a. According to the Illinois Administrative Procedures Act, each state agency must require license holders to certify the
following: “I hereby certify, under penalty of perjury, that (Please check only one)
 I am not subject to a child support order”
 I am not more than 30 days delinquent in complying with a child support order”
 I am more than 30 days delinquent in complying with a child support order”
Failure to so certify may result in denial of the application/renewal; and making a false statement may subject the
licensee to contempt of court (5ILCS 10/1 0-65 c)
b. I hereby certify that if a license is granted under this application, I agree to conform and conduct my Business in
accordance with the provisions set forth in the Illinois Egg & Egg Products Rules & Regulations and the regulations
pursuant, thereto.
c. I hereby certify that the information contained herein is true and accurate to the best of my knowledge.
Name of the Owner (Please Print or Type)
Signature of Owner, Partner, Officer of Corporation
Date
(This application must be signed by the Owner, if an individual, by one of the partners, if a partnership, or by an officer
of the corporation if incorporated. Please return to address listed on top of application.)
Application for Illinois Egg License • Page 2 of 2
Page of 2