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:

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

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

*Be sure to submit forms in duplicate.
One copy will be returned to applicant upon certification.

DEPARTMENT USE ONLY

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


Date ________________________ Signature ________________________________________

                                                                                          Fertilizer Control Official