Free 47075.FH11 - Indiana

APPLICATION FOR APIARY REGISTRATION
State Form 47075 (R / 12-00)

DNR USE ONLY DO NOT WRITE IN THIS SPACE
Certificate number

FILL OUT AND RETURN AT ONCE TO: INDIANA DEPARTMENT OF NATURAL RESOURCES DIVISION OF ENTOMOLOGY AND PLANT PATHOLOGY 402 WEST WASHINGTON STREET, ROOM W290 INDIANAPOLIS, INDIANA 46204 Telephone: 317-232-4120 FAX: 317-232-2649

To the Chief Apiary Inspector;

Date ________________ , 20____

In voluntary compliance with the Apiary Section of the Horticulture and Apiary Laws of Indiana (IC 14-24-8) pertaining to the annual registration of bees, I herewith submit application for registration of my bees. In addition, I have listed the location of each apiary or apiaries, whether on my own property or on that of another, and I will notify the Chief Apiary Inspector of any change in the location of said apiary or apiaries. __________________________________________________________
Signature of applicant

PLEASE PRINT Name of applicant Date (month, day, year)

Mailing address, street or R.F.D.

City

State

ZIP code

Telephone number

County

Please fill out the reverse side; if more space is needed extra blanks may be obtained from the Chief Apiary Inspector.

Indicate any change in mailing address or location of apiary. If no change has been made since the original registration check here:

Last year's certificate number

Be specific on location of apiary; street number or road name or number, nearest town, directions for reaching apiary.
Number of colonies Name of land owner Location of apiary:

APIARY 1
County Township Telephone number

Number of colonies Name of land owner Location of apiary:

APIARY 2
County Township Telephone number

APIARY 3
Number of colonies Name of land owner Location of apiary: County Township Telephone number

Number of colonies Name of land owner Location of apiary:

APIARY 4
County Township Telephone number

Number of colonies Name of land owner Location of apiary:

APIARY 5
County Township Telephone number