Free 36560.FH11 - Indiana

APPLICATION FOR PERMIT TO HANDLE MILK OR MILK PRODUCTS
State Form 36560 (R/10-08)

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INDIANA STATE BOARD OF ANIMAL HEALTH DAIRY DIVISION 805 Beachway Drive, Suite 50 Indianapolis, IN 46224 Telephone: (317) 227-0350 Fax number: (317) 227-0330

Pursuant to the provisions of IC 15-18-1-3, the following is an application form for a permit to handle, process, store, pasteurize, package, or prepare for distribution of milk or milk products. Such permits remain valid, pursuant to compliance with provisions of law and regulations of the Board of Animal Health, until December 30th of each year, and must be renewed at that time. INSTRUCTIONS: 1. Please print or type. 2. Please complete this form and return it to the address above. 3. Please list name and location of each manufacturer of finished products supplied to you, and/or list names and locations of all distribution points in Indiana on reverse side. (if applicable) 4. Please list name and location of each Grade A dairy manufacturer you supply on reverse side.

INFORMATION FOR PERMIT
To operate as: (please check one) Grade A milk / milk products processor Milk / milk products distributor
Indiana permit number

Manufactured milk products processor Single service container manufacture
Home state permit number (if outside of Indiana)

Transfer station Wash station

Receiving station

Date (month, day, year)

Name of establishment

Telephone number ( )

Fax number ( )

Address of establishment (number and street, city, state and ZIP code)

Name of responsible party making application

Legal status of firm (corporation, privately owned)

Name of subsidiary or related firms

Type of products handled, processed and/or manufactured

APPLICANT AFFIRMATION
This is to affirm under penalty of perjury that the above facts are true and that I am complying with, and will continue to comply with, all laws and rules pertaining to my business.
Signature of applicant / responsible party Date of signature (month, day, year)

Printed or typed name of applicant

Title of applicant

DO NOT WRITE BELOW THIS LINE
This is to certify that said premises have been found to be in compliance with applicable rules and regulations either by direct examination or certification by a legally constituted health jurisdiction or official agency. The issuance of a permit is hereby requested.
State milk regulatory agency Date (month, day, year)

SOURCE OF FINISHED PRODUCTS ACQUIRED FOR DISTRIBUTION IN INDIANA
Does manufacturer, processor, or his agent deliver product to you, or do you pick it up on his premises? (Please check one) PRODUCT 1. 2. 3. 4. 5. 6. 7. 8. NAME OF MANUFACTURER
(number and street, city, state and ZIP code)

ADDRESS OF MANUFACTURER

DELIVERS

PICK UP

LIST NAME AND LOCATION OF EACH DISTRIBUTION POINT WHICH YOU OWN IN INDIANA
NAME OF DISTRUBUTION POINT 1. 2. 3. 4. 5. 6. 7. 8. ADDRESS OF DISTRIBUTION POINT (number and street, city, state and ZIP code)

LIST NAME AND LOCATION OF EACH DAIRY MANUFACTURER YOU SUPPLY
NAME OF MANUFACTURER 1. 2. 3. 4. 5. 6. 7. 8. ADDRESS OF MANUFACTURER (number and street, city, state and ZIP code)