Form AG-00128 "New Application for Fertilizer License" - Minnesota

What Is Form AG-00128?

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 November 6, 2019;
  • 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 fillable version of Form AG-00128 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-00128 "New Application for Fertilizer License" - Minnesota

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625 ROBERT STREET NORTH, SAINT PAUL, MN 55155-2538
WWW.MDA.STATE.MN.US
Pesticide & Fertilizer Management Division
Phone: 651-201-6379 carol.durden@state.mn.us Minn. Stat. Sec. 18C.305
20
New Application for Fertilizer License
New License Number
License Period of January 1 to December 31
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 .
COMPANY INFORMATION (company/location being licensed)
MAILING ADDRESS (if different)
Company Legal Name:
Name:
DBA (if different):
Mailing Address:
Street Address (No PO Box) for License Location:
City:
State:
Zip Code:
Company Telephone:
City:
State:
Zip Code:
Minnesota Tax ID or SSN:
County:
ADDITIONAL LICENSE LOCATION (within city limits of city listed above)
(No PO BOX)
Street Address
City
State
Zip Code
County
If location was previously licensed, name of the previous owner:
LICENSE CATEGORIES (a separate license is required for Mobile Blending Units and one license covers all locations outside of Minnesota)
Manufacture Secondary or Micronutrient Products
Apply Bulk Ag Fertilizer
Store Anhydrous Ammonia
(a label/label facsimile must be submitted for each product in this category)
Mobile Blending Unit (Ag use only) Number of Mobile Blending Units
Apply Non-Ag Fertilizer
Store Dry Bulk Fertilizer
($100 first unit, $50 for each additional unit):
Manufacture Fertilizer
Sell Ag Fertilizer
Store Liquid Bulk Fertilizer
(a label/label facsimile must be submitted for each product in this category)
APPLICATION FEES (if you have more than one Mobile Blending Unit, there are additional charges. Please contact the MDA for more Information)
Application Fee $ 100.00
600288(3100)
Agricultural Chemical Response and Reimbursement Surcharge (ACRRA) $ 28.00
600339(3310)
Total Due $ 128.00
RETURN THIS FORM WITH YOUR CHECK MADE PAYABLE TO
FOR OFFICE USE ONLY
Minnesota Department of Agriculture
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. I also certify that fertilizer products distributed
in Minnesota by my company comply with Minnesota Statue 18C, and do not contain more than 500 parts per million by weight of arsenic.
Signature:
Name (Please Print):
Date:
Title:
Phone:
Email:
Fax:
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request
AG-00128
by calling 651-201-6000. TTY users can call the Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.
11/6/19
625 ROBERT STREET NORTH, SAINT PAUL, MN 55155-2538
WWW.MDA.STATE.MN.US
Pesticide & Fertilizer Management Division
Phone: 651-201-6379 carol.durden@state.mn.us Minn. Stat. Sec. 18C.305
20
New Application for Fertilizer License
New License Number
License Period of January 1 to December 31
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 .
COMPANY INFORMATION (company/location being licensed)
MAILING ADDRESS (if different)
Company Legal Name:
Name:
DBA (if different):
Mailing Address:
Street Address (No PO Box) for License Location:
City:
State:
Zip Code:
Company Telephone:
City:
State:
Zip Code:
Minnesota Tax ID or SSN:
County:
ADDITIONAL LICENSE LOCATION (within city limits of city listed above)
(No PO BOX)
Street Address
City
State
Zip Code
County
If location was previously licensed, name of the previous owner:
LICENSE CATEGORIES (a separate license is required for Mobile Blending Units and one license covers all locations outside of Minnesota)
Manufacture Secondary or Micronutrient Products
Apply Bulk Ag Fertilizer
Store Anhydrous Ammonia
(a label/label facsimile must be submitted for each product in this category)
Mobile Blending Unit (Ag use only) Number of Mobile Blending Units
Apply Non-Ag Fertilizer
Store Dry Bulk Fertilizer
($100 first unit, $50 for each additional unit):
Manufacture Fertilizer
Sell Ag Fertilizer
Store Liquid Bulk Fertilizer
(a label/label facsimile must be submitted for each product in this category)
APPLICATION FEES (if you have more than one Mobile Blending Unit, there are additional charges. Please contact the MDA for more Information)
Application Fee $ 100.00
600288(3100)
Agricultural Chemical Response and Reimbursement Surcharge (ACRRA) $ 28.00
600339(3310)
Total Due $ 128.00
RETURN THIS FORM WITH YOUR CHECK MADE PAYABLE TO
FOR OFFICE USE ONLY
Minnesota Department of Agriculture
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. I also certify that fertilizer products distributed
in Minnesota by my company comply with Minnesota Statue 18C, and do not contain more than 500 parts per million by weight of arsenic.
Signature:
Name (Please Print):
Date:
Title:
Phone:
Email:
Fax:
In accordance with the Americans with Disabilities Act, this information is available in alternative forms of communication upon request
AG-00128
by calling 651-201-6000. TTY users can call the Minnesota Relay Service at 711. The MDA is an equal opportunity employer and provider.
11/6/19