Farm Products

Fertilizer/Lime
Registration

1. Print form, complete, and submit in duplicate.
2. Make check payable to COMMONWEALTH OF MASSACHUSETTS.
3. Send check, application forms with unattached labels to:

For period ending December 31, _____:

Firm Name
Street Address
City
State
Zip
Phone
Date
Name of Signatory
Title
Signature

PRODUCTS TO BE REGISTERED

1.
2.
3.
4.
5.

Enclosed is fee of $ _________ covering registration of ________ products at $100 per product, payable to Commonwealth of Massachusetts.

DEPARTMENT USE ONLY

This certifies that the above-named applicant is hereby licensed to sell the above products of commercial feed in the State of Massachusetts for the period ending December 31, ____, when sold, offered, or exposed for sale under the product name, guaranteed analysis and declarations of ingredients exactly as they appear on the enclosed labels.

Date _________________ Signature ______________________________________

                                                                                Feed Control Official