Free 49599.FH11 - Indiana

APPLICATION FOR SHIPPING BEES AND ELEMENTS OF BEEKEEPING INTO INDIANA
State Form 49599 (1-00) Approved by State Board of Accounts, 2000

INSTRUCTIONS:
1. Please read and complete both sides of this application. 2. Attach an Inspection Certificate (from the place of origin) to this form. 3. Mail completed form and attached Inspection Certificate (or copy) to address listed on back.

State of Indiana Department of Natural Resources Division of Entomology and Plant Pathology 402 West Washington Street, Room W290 Indianapolis, IN 46204 (317) 232-4120

A beekeeper may not ship or bring elements of beekeeping into Indiana from another state or country unless the elements of beekeeping are accompanied by: (a) A permit issued by the Division of Entomology and Plant Pathology under IC 14-24-8-4; and (b) A certificate from the place of origin. The certificate from the place of origin must state: (1) The apiary from which elements of beekeeping are to be shipped (except queens and combless bees) was inspected not more than thirty (30) days before shipment. (2) The apiary from which the queens or combless bees are to be shipped was inspected not more than sixty (60) days before shipment. (3) The inspection took place during active brood rearing and was found free of pests and pathogens. IC 14-24-8-4(a, b and c)

1 SHIPPER
Name of shipper Address (number and street or RR) City

PLEASE PRINT OR TYPE
Name of contact person Telephone number State ZIP code

2 SHIPMENT FROM
Name of apiary or individual Address (number and street or RR) City Location of apiary (if different from address above) Name of contact person Telephone number State ZIP code

3 TYPE AND QUANTITY OF SHIPMENT
Packaged bees Queens Nucs Hives

4 DATE OF ENTRY INTO INDIANA
Day Month Year

5 FINAL DESTINATION OF BEES AND ELEMENTS OF BEEKEEPING
Additional names may be listed on the back of this form or on an attached copy. (Must be completed per IC 14-24-8-4.) Name Address Amount Type

Continued on Back

6 SIGNATURE
By signing this application, I agree to abide by the Indiana Department of Natural Resources current laws and regulations governing the movement of elements of beekeeping into the state of Indiana. I also realize that the permit, if issued, may be revoked at any time if it was issued as a result of fraud or misrepresentation or for non-compliance with the terms of this application. (IC 14-24-11-2) Signature of applicant (must be signed manually) Date signed

FINAL DESTINATION (CONTINUED) - Additional names may be listed on on an attached copy.
Name Address Amount Type

WHEN COMPLETE, MAIL THIS FORM TO:
State of Indiana Department of Natural Resources Division of Entomology and Plant Pathology 402 West Washington Street, Room W290 Indianapolis, IN 46204 (317) 232-4120