"Illinois Premises Identification Registration" - Illinois

Illinois Premises Identification Registration is a legal document that was released by the Illinois Department of Agriculture - a government authority operating within Illinois.

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ILLINOIS PREMISES IDENTIFICATION REGISTRATION
Illinois Department of Agriculture
Bureau of Animal Health and Welfare
801 E. Sangamon Avenue
PO Box 19281
Instructions:
Springfield, IL 62794-9281
1. Please type or print legibly
Telephone: 217-782-4944
2. Return forms to the above email or mailing address
Fax: 217-558-6033
3. For questions, contact the Bureau of Animal Health and Welfare at the above telephone number or
Email: AGR.Premises@Illinois.gov
e-mail address.
Purpose of this form (mark one)
If update, enter premise identification number
Register a premises for the first time ☐ Update information on a registered premises
(if known)
Preferred method to receive premises registration card (check one)
MAIL
EMAIL
PART I – CONTACT/ACCOUNT HOLDER INFORMATION
This section specifies the contact information for the livestock premises. This information will be utilized during an animal health emergency for
notification purposes. This process is essential for protecting the industry from the spread of disease. For corporations with contract growers, please
list both a corporate and
/grower contact.
premise
Name of business/farm (optional)
Name of primary contact (first, middle, last)
Mailing address of primary contact (number and street, city, state and ZIP code)
County
Business telephone number
Home telephone number
Cellular telephone number
Fax Number
E-mail address
Name of secondary contact (first, middle, last)
Mailing address of secondary contact (number and street, city, state and ZIP code)
County
Business telephone number
Home telephone number
Cellular telephone number
Fax Number
E-mail address
PART II – PREMISES INFORMATION
Name/Description of premises (Example: “home,” “heifer place,” “farrow to finish”)
Address same as
Physical address of premises (No PO/RR – 911 address only)(number, street, city, and Zip code)
County
account ☐
Geographic information System (GIS) coordinates (only required if no 911 address applies)
Latitude___________________________
Longitude:______________________________
Type of operation (check all that apply):
☐Farm/Production Unit/Stable
☐4-H Participant Only
☐Slaughter Plant
☐Port of Entry
☐Clinic
☐Laboratory
☐Market/Collection Point
☐Research Facility
☐Quarantine Facility
☐Exhibition/Show Site
☐Zoo
☐Rendering
☐Feed Mill
☐Truck Wash
☐Other:___________________________________________
Species at premises (check all that apply)
☐Beef Cattle
☐Chickens
☐Swine
☐Sheep
☐Horses
☐Deer
☐Dairy Cattle
☐Turkeys
☐Waterfowl
☐Goats
☐Bison
☐Elk
☐Other:________________________________
INFORMATION ON ADDITIONAL PREMISES
If you have more than one premises (animal location), please complete page 2 of this form.
Page 1 of 2
ILLINOIS PREMISES IDENTIFICATION REGISTRATION
Illinois Department of Agriculture
Bureau of Animal Health and Welfare
801 E. Sangamon Avenue
PO Box 19281
Instructions:
Springfield, IL 62794-9281
1. Please type or print legibly
Telephone: 217-782-4944
2. Return forms to the above email or mailing address
Fax: 217-558-6033
3. For questions, contact the Bureau of Animal Health and Welfare at the above telephone number or
Email: AGR.Premises@Illinois.gov
e-mail address.
Purpose of this form (mark one)
If update, enter premise identification number
Register a premises for the first time ☐ Update information on a registered premises
(if known)
Preferred method to receive premises registration card (check one)
MAIL
EMAIL
PART I – CONTACT/ACCOUNT HOLDER INFORMATION
This section specifies the contact information for the livestock premises. This information will be utilized during an animal health emergency for
notification purposes. This process is essential for protecting the industry from the spread of disease. For corporations with contract growers, please
list both a corporate and
/grower contact.
premise
Name of business/farm (optional)
Name of primary contact (first, middle, last)
Mailing address of primary contact (number and street, city, state and ZIP code)
County
Business telephone number
Home telephone number
Cellular telephone number
Fax Number
E-mail address
Name of secondary contact (first, middle, last)
Mailing address of secondary contact (number and street, city, state and ZIP code)
County
Business telephone number
Home telephone number
Cellular telephone number
Fax Number
E-mail address
PART II – PREMISES INFORMATION
Name/Description of premises (Example: “home,” “heifer place,” “farrow to finish”)
Address same as
Physical address of premises (No PO/RR – 911 address only)(number, street, city, and Zip code)
County
account ☐
Geographic information System (GIS) coordinates (only required if no 911 address applies)
Latitude___________________________
Longitude:______________________________
Type of operation (check all that apply):
☐Farm/Production Unit/Stable
☐4-H Participant Only
☐Slaughter Plant
☐Port of Entry
☐Clinic
☐Laboratory
☐Market/Collection Point
☐Research Facility
☐Quarantine Facility
☐Exhibition/Show Site
☐Zoo
☐Rendering
☐Feed Mill
☐Truck Wash
☐Other:___________________________________________
Species at premises (check all that apply)
☐Beef Cattle
☐Chickens
☐Swine
☐Sheep
☐Horses
☐Deer
☐Dairy Cattle
☐Turkeys
☐Waterfowl
☐Goats
☐Bison
☐Elk
☐Other:________________________________
INFORMATION ON ADDITIONAL PREMISES
If you have more than one premises (animal location), please complete page 2 of this form.
Page 1 of 2
A unique premise identification number (PIN) is recommended for each non-contiguous location associated with the sale, purchase, and/or exhibition of
livestock. Sites under the same management but separated by no more than ¼ mile may be considered contiguous and require only one premise
identification number.
ADDITIONAL PREMISES INFORMATION
Name/Description of premises (Example: “home,” “heifer place,” “farrow to finish”)
Physical address of premises (No PO/ RR – 911 address only)(number and street, city, and ZIP code)
County
Geographic information System (GIS) coordinates (only required if no 911 address applies)
Latitude___________________________
Longitude:______________________________
Type of operation (check all that apply):
☐Farm/Production Unit/Stable
☐4-H Participant Only
☐Slaughter Plant
☐Port of Entry
☐Clinic
☐Laboratory
☐Market/Collection Point
☐Research Facility
☐Quarantine Facility
☐Exhibition/Show Site
☐Zoo
☐Rendering
☐Feed Mill
☐Truck Wash
☐Other:___________________________________________
Species at premises (check all that apply)
☐Beef Cattle
☐Chickens
☐Swine
☐Sheep
☐Horses
☐Deer
☐Dairy Cattle
☐Turkeys
☐Waterfowl
☐Goats
☐Bison
☐Elk
☐Other:________________________________
ADDITIONAL PREMISES INFORMATION
Name/Description of premises (Example: “home,” “heifer place,” “farrow to finish”)
Physical address of premises (No PO/RR – 911 address only)(number and street, city, and ZIP code)
County
Geographic information System (GIS) coordinates (only required if no 911 address applies)
Latitude___________________________
Longitude:______________________________
Type of operation (check all that apply):
☐Farm/Production Unit/Stable
☐4-H Participant Only
☐Slaughter Plant
☐Port of Entry
☐Clinic
☐Laboratory
☐Market/Collection Point
☐Exhibition/Show Site
☐Research Facility
☐Quarantine Facility
☐Zoo
☐Rendering
☐Feed Mill
☐Truck Wash
☐Other:___________________________________________
Species at premises (check all that apply)
☐Beef Cattle
☐Chickens
☐Swine
☐Sheep
☐Horses
☐Deer
☐Dairy Cattle
☐Turkeys
☐Waterfowl
☐Goats
☐Bison
☐Elk
☐Other:________________________________
If you have more premises (animal location) please complete additional sheets.
For large integrators/companies, please request a spreadsheet template at (217) 782-4944 or AGR.Premises@Illinois.gov
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