Free prem page 2.indd - Indiana

Premise Information
State Form 52010 (R2 /11-05)

TO ACCOMPANY STATE FORM 52009

Page________ of________ Business Farm Name _____________________________

Part 2:

Complete a premise form for each separate location where animals are housed. Sites under the same management but separated by no more than a county road may be considered contiguous.

Primary Premise Information
Premise Name/Description: Premise Address (physical location, no P.O. Boxes). Check as appropriate: Premise address is the same as Business/Farm account address on page one. Premise address is unknown. Provide legal land description.
Township Range Section example "home place", "heifer place"

Premise address is: City

State

ZIP

County

Premise Type (check all that apply): Farm/Producer Unit/Stable Clinic Exhibition site (show site) Market/collection point Research Facility Non-producer Participant Quarantine Facility Rendering Slaughter plant Tagging site Zoo Species at Premise (check all that apply): Cattle/Bison Swine Sheep Goats Horse Poultry Deer/Elk Camelid Emu/Ostrich Is the contact for this location the same as the primary contact listed on part 1? If no, complete the following: YES NO

Contact Contact

Phone Number Phone Number

Additional Premise Information
Premise Name/Description: Premise Address (physical location, no P.O. Boxes). Check as appropriate: Premise address is the same as Business/Farm account address on page one. Premise address is unknown. Provide legal land description.
Township Range Section example "home place", "heifer place"

Premise address is: City

State

ZIP

County

Premise Type (check all that apply): Farm/Producer Unit/Stable Clinic Exhibition site (show site) Market/collection point Research Facility Non-producer Participant Quarantine Facility Rendering Slaughter plant Tagging site Zoo Species at Premise (check all that apply): Cattle/Bison Swine Sheep Goats Horse Poultry Deer/Elk Camelid Emu/Ostrich Is the contact for this location the same as the primary contact listed on part 1? If no, complete the following: YES NO

Contact Contact

Phone Number Phone Number
If you have more premises (animal locations) please complete additional sheets. Return forms to: Indiana State Board of Animal Health, 805 Beachway Dr. Ste. 50, Indianapolis, IN 46224 For questions, contact BOAH: 317-227-0328 or email: [email protected]

Page________ of________ Business Farm Name _____________________________

Additional Premise Information
Premise Name/Description: Premise Address (physical location, no P.O. Boxes). Check as appropriate: Premise address is the same as Business/Farm account address on page one. Premise address is unknown. Provide legal land description.
Township Range Section example "home place", "heifer place"

Premise address is: City

State

ZIP

County

Premise Type (check all that apply): Farm/Producer Unit/Stable Clinic Exhibition site (show site) Market/collection point Research Facility Non-producer Participant Quarantine Facility Rendering Slaughter plant Tagging site Zoo Species at Premise (check all that apply): Cattle/Bison Swine Sheep Goats Horse Poultry Deer/Elk Camelid Emu/Ostrich Is the contact for this location the same as the primary contact listed on part 1? If no, complete the following: YES NO

Contact Contact

Phone Number Phone Number

Additional Premise Information
Premise Name/Description: Premise Address (physical location, no P.O. Boxes). Check as appropriate: Premise address is the same as Business/Farm account address on page one. Premise address is unknown. Provide legal land description.
Township Range Section example "home place", "heifer place"

Premise address is: City

State

ZIP

County

Premise Type (check all that apply): Farm/Producer Unit/Stable Clinic Exhibition site (show site) Market/collection point Research Facility Non-producer Participant Quarantine Facility Rendering Slaughter plant Tagging site Zoo Species at Premise (check all that apply): Cattle/Bison Swine Sheep Goats Horse Poultry Deer/Elk Camelid Emu/Ostrich Is the contact for this location the same as the primary contact listed on part 1? If no, complete the following: YES NO

Contact Contact

Phone Number Phone Number

If you have more premises (animal locations) please complete additional sheets. Return forms to: Indiana State Board of Animal Health, 805 Beachway Dr. Ste. 50, Indianapolis, IN 46224 For questions, contact BOAH: 317-227-0328 or email: [email protected]