Free 42898.pdf - Indiana

APPLICATION FOR NURSERY DEALER'S LICENSE
State Form 42898 (R10/10-03) Form Approved by State Board of Accounts, 2003

Indiana Department of Natural Resources Division of Entomology & Plant Pathology (317) 232-4120

License Renewal

New Nursery Dealer

STATE OFFICE USE ONLY
Date Check Number Amount $ License Number

INSTRUCTIONS: 1. PLEASE READ AND COMPLETE BOTH SIDES OF THIS APPLICATION 2. Fee is $50.00 per business location for each license. 3. See Reverse for Payment Options & Address. 4. If your check is returned to us for insufficient funds, your license could be DENIED.

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1

In compliance with the definition of the term "dealer" given in IC 14-8-2-65(3) and IC 14-24-7 my business as a dealer of nursery stock makes it necessary that I obtain a Nursery Dealer's License. I am making application for such license and will deal only in nursery stock certified as being free from injurious and destructive pests and diseases. The Nursery Dealer's License expires December 31 of each year, and must be renewed annually. PLEASE PRINT OR TYPE Name of Contact Person

Name of Firm

Address (number and street or R. R.)

Telephone Number

(
City County State

)
ZIP code

Mailing address (if different from above location) (number and street or R. R.) City County State ZIP code

2

My business address, name &/or phone number has changed in the past year. Report any changes in the space provided below. Former Telephone Number

Former Name of Firm Former Address (number and street or R. R.) City County

(

)

State

ZIP code

3

I grew nursery stock that was Inspected and Certified during the previous growing season (IC 14-24-5). My "Certificate of Nursery Inspection" number is:__________________________ (This number will provide verification that you are eligible for the $20.00 Nursery Dealer's License. This is NOT your prior year's Nursery Dealer's License number). I plan to grow stock in the future.

4

Nature of business

Contractor

Landscaper

Garden Center

Department Store

Other (specify)

PLEASE LIST NAMES AND COMPLETE ADDRESSES OF PERSONS OR FIRMS FROM WHOM YOU PURCHASE INSPECTED AND CERTIFIED STOCK. (must be completed per IC 14-24-7-2)

5

Additional sources may be listed on the back of this form or on an attached copy. Please include the complete business name and address of sources. You must list all persons and firms (currently known or anticipating) from whom you purchase stock.

_____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________ _____________________________________________________________
PLEASE READ AND COMPLETE BOTH SIDES OF THIS APPLICATION. ALL INCOMPLETE APPLICATIONS WILL BE RETURNED.

AFFIRMATION OF BUSINESS PURPOSE IN OBTAINING A NURSERY DEALER'S LICENSE

6A

Any intentional false statement on this application is a violation of law, punishable under the penalty of perjury. - I, the undersigned, do affirm that I am either: A. B. A "nurseryman" means a person who owns, leases, manages or controls a nursery; or A "dealer" who grows, handles or buys nursery stock for the purpose of reselling or reshipping that stock in Indiana. I affirm that I am properly qualified to be licensed under Indiana law as one who is selling or distributing stock pursuant to IC 14-24. I affirm that this license will not be used solely to purchase plants for my personal use or use by family members & for landscaping around my place of business. I consent to having my Name and Business Information published as part of an electronic directory of Licensed Dealer's.

NURSERY STOCK means botanically classified hardy perennial or biennial trees, shrubs, vines, fruit pits and other plants or plant parts capable of propagation. The term does not include corms, tubers, field vegetables, or flower seeds. (IC14-8-2-184) The purpose of the Nursery Dealer License is to insure that only inspected and certified nursery stock is sold in Indiana. The Nursery Dealer License application requires a list of sources where nursery stock is purchased. The record of sources is compared with nursery inspection records to ensure that certified stock is sold in Indiana.

6B

Both State and Federal law are requiring the disclosure of Social Security Numbers. The purpose of the disclosure is to aid in the collection of delinquent child support. The information will not be accessible by the public. The gathering of this information is mandated under Indiana Code IC 12-17-2-34(a)(5)(G)(vi) for purposes of the Title IV-D program.
Social Security Number/ Federal ID Number Date Signed (Month, Day, Year)

Signature of Applicant (Must be manually signed)*

* Signature attests to both 6A & 6B

Select Payment Method: Check: Cash: - No.________________________________________ - No.__________________________________ - $___________________________________________ Exp. Date:__________________

Make Payments to: "DNR" Please Remit all Payments to:
INDIANA DEPARTMENT OF NATURAL RESOURCES DNR SALES UNIT 402 WEST WASHINGTON STREET, ROOM W-160 INDIANAPOLIS, IN. 46204-2742

Money Order:

Circle One:

______________________________________________________
PRINT name as it appears on Credit Card

______________________________
Card No.

______________________________
Signature

Do you have a computer with Internet access? If so please provide your email address for exotic pest & regulatory information updates.
ADDITIONAL SOURCES (continued) ATTACH A SEPARATE SHEET IF NECESSARY

Email address:

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