Form AG-03246 "New Commercial Animal Waste Technician Company License Application" - Minnesota

What Is Form AG-03246?

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

Form Details:

  • Released on January 9, 2018;
  • The latest edition provided by the Minnesota 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 printable version of Form AG-03246 by clicking the link below or browse more documents and templates provided by the Minnesota Department of Agriculture.

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Download Form AG-03246 "New Commercial Animal Waste Technician Company License Application" - Minnesota

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Pesticide & Fertilizer Management Division Ph. 651-201-6615 Fax 651-201-6105
New License Number:
Minn. Stat. Ch. 18C.430
20___ NEW COMMERCIAL ANIMAL WASTE TECHNICIAN COMPANY LICENSE APPLICATION
The data on this form will be used to process your application. You must provide your Minnesota Tax ID number. If you do not have one, you must provide your social security
number (MS Sec 270C.72). We are required by law to collect this information and we cannot grant your license without it. No one will have access to your social security number
except those permitted access by law, your written consent, court order, or those department employees whose job duties require access. Pursuant to MS Sec 297A.66 if your
company maintains within the state an office or place of distribution or sales person or other employee that solicits, sells or delivers goods or services in the state you must have a
Minnesota Tax ID number. If you are unsure if you need a Minnesota Tax ID, contact the Minnesota Department of Revenue at www.taxes.state.mn.us.
Does your company maintain within the state an office or place of distribution or sales person or other employee that solicits,
sells or delivers goods or services in the state? Yes __ or No__. If yes, enter MN Tax ID number in the space provided below .
(Please print)
Company Information:
Company Legal Name
MN Tax ID or if none, Social Security Number
DBA (if different)
Company Mailing Address (if different)
Company Street Address (No PO Box)
City
State
Zip Code
City
State
Zip Code
Company Telephone
County
Site Manager:
Commercial Animal Waste Technician Company License requires that you employ at least one Site Manager.
Site Manager Name:_________________________________________Site Manager License Number:______________________
Workers' Compensation:
Do you have any paid or otherwise compensated employees in Minnesota? __Yes __No If yes, complete the following information:
Insurance Company Name
Effective Date
Expiration Date
Policy #
You must provide acceptable evidence of compliance with the Workers' Compensation Insurance Law (MS Sec 176.182). If you are self-insured, attach a copy of the exemption
order from the Commissioner of Commerce authorizing self-insurance. For questions, contact the Minnesota Department of Labor and Industry at www.doli.state.mn.us.
Proof of Financial Responsibility is required by the MN Fertilizer, Soil & Plant Amendment Law (Minn. Stat. Ch. 18C).
Financial Responsibility: (Check all that apply)
Liability Insurance
Net Asset Statement
Performance or Surety Bond
Application Fees:
328010-
Application Fee:
$100.00
600301(3103)
Return this form with your check made payable to:
MINNESOTA DEPARTMENT OF AGRICULTURE
Total Due:
$100.00
Attn: Cashier
625 Robert Street North
Saint Paul, MN 55155-2538
Licenses are not transferable and fees are not refundable.
I hereby certify that the information contained in and submitted with this form is true and correct.
For Office Use Only
Signature: ________________________________________
Date: ____________________
Name (Please print): ________________________________
Title: ____________________
Contact Telephone: ________________________ Fax Number: _______________________
E-mail Address: ______________________________________________________________
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request by calling 651-201-6000. TTY users can call the
Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.
AG-03246 (01/09/2018)
Date Computer Updated:__________________________
Pesticide & Fertilizer Management Division Ph. 651-201-6615 Fax 651-201-6105
New License Number:
Minn. Stat. Ch. 18C.430
20___ NEW COMMERCIAL ANIMAL WASTE TECHNICIAN COMPANY LICENSE APPLICATION
The data on this form will be used to process your application. You must provide your Minnesota Tax ID number. If you do not have one, you must provide your social security
number (MS Sec 270C.72). We are required by law to collect this information and we cannot grant your license without it. No one will have access to your social security number
except those permitted access by law, your written consent, court order, or those department employees whose job duties require access. Pursuant to MS Sec 297A.66 if your
company maintains within the state an office or place of distribution or sales person or other employee that solicits, sells or delivers goods or services in the state you must have a
Minnesota Tax ID number. If you are unsure if you need a Minnesota Tax ID, contact the Minnesota Department of Revenue at www.taxes.state.mn.us.
Does your company maintain within the state an office or place of distribution or sales person or other employee that solicits,
sells or delivers goods or services in the state? Yes __ or No__. If yes, enter MN Tax ID number in the space provided below .
(Please print)
Company Information:
Company Legal Name
MN Tax ID or if none, Social Security Number
DBA (if different)
Company Mailing Address (if different)
Company Street Address (No PO Box)
City
State
Zip Code
City
State
Zip Code
Company Telephone
County
Site Manager:
Commercial Animal Waste Technician Company License requires that you employ at least one Site Manager.
Site Manager Name:_________________________________________Site Manager License Number:______________________
Workers' Compensation:
Do you have any paid or otherwise compensated employees in Minnesota? __Yes __No If yes, complete the following information:
Insurance Company Name
Effective Date
Expiration Date
Policy #
You must provide acceptable evidence of compliance with the Workers' Compensation Insurance Law (MS Sec 176.182). If you are self-insured, attach a copy of the exemption
order from the Commissioner of Commerce authorizing self-insurance. For questions, contact the Minnesota Department of Labor and Industry at www.doli.state.mn.us.
Proof of Financial Responsibility is required by the MN Fertilizer, Soil & Plant Amendment Law (Minn. Stat. Ch. 18C).
Financial Responsibility: (Check all that apply)
Liability Insurance
Net Asset Statement
Performance or Surety Bond
Application Fees:
328010-
Application Fee:
$100.00
600301(3103)
Return this form with your check made payable to:
MINNESOTA DEPARTMENT OF AGRICULTURE
Total Due:
$100.00
Attn: Cashier
625 Robert Street North
Saint Paul, MN 55155-2538
Licenses are not transferable and fees are not refundable.
I hereby certify that the information contained in and submitted with this form is true and correct.
For Office Use Only
Signature: ________________________________________
Date: ____________________
Name (Please print): ________________________________
Title: ____________________
Contact Telephone: ________________________ Fax Number: _______________________
E-mail Address: ______________________________________________________________
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request by calling 651-201-6000. TTY users can call the
Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.
AG-03246 (01/09/2018)
Date Computer Updated:__________________________