Free 50907.FH11 - Indiana

APPLICATION FOR ROUTE / TRUCK PERMIT
State Form 50907 (R / 9-08)

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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 milk route / truck permit.
INSTRUCTIONS: 1. 2. 3. 4. 5. Permit issued Please print clearly. Only one tank permit for each application. Permits must be renewed each year. Before the application can be considered, it must be filled out completely, signed by the applicant, and the tank inspected. Renewal permits will only be issued if tank / truck is inspected within the last year. Please complete this form and return it via fax or mail to the address above. Tag(s) issued Please check one:

Please check one:

New
Name of applicant

Renewal

Bulk farm route truck

Can milk route truck

Over the road (OTR) transport tank
Permit number

Address (number and street, city, state and ZIP code) Telephone number ( ) Bulk Tank Unit (BTU) number(s) Bulk tank serial number and make Truck number replaced Cell phone number ( ) Route number(s) Fax number ( )

Is this the same truck permitted last year? Yes No
License plate number of truck

Yes

No

If No, does this truck replace another?
List states and/or plants you regularly unload in

Company unit number

Other products hauled or handled

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

This is to affirm that I have examined said vehicle and find it in compliance with the rules, and I hereby approve this application and request the issuance of a permit. Authorized signature required for new trucks only.
Signature of authorized representative of the Board of Animal Health Date of signature (month, day, year)