DEPARTMENT OF ~ 7::!:_ RE I Iowa Department of Agriculture and Land Stewardship Commercial Feed Bureau 502 E 9th St Des Moines IA 50319 Phone (515) 281-8597 A valid Iowa Commercial Feed License is needed before a certificate is issued. ORDER FORM FOR CERTIFICATE OF FREE SALE Feed Manufacturer Information Name of Maufacturer Feed License Number Email Street / PO Box City State Zip Code Contact Person Direct Phone Fax Product Name as It Should Appear on the Certificate Destination Country Number of Products Per Certificate Number of Certificates Requested X Fee Per Certificate = Total Certificate of Free Sale X $ 35.00 = $ Departmental Seal X $ 10.00 = $ Notarized Affidavit X $ 35.00 = $ Feed Manufacturer/Dealer License Notarized X $ 10.00 = $ Good Manufacturing Practices Inspection (Inspection good for 2 years) X $ 2,744.37 = $ Total Number Enclosed Grand Total $ Requested Specialty Statement, if applicable. Send Certificate by US MAIL FED EX OTHER Fed Ex Account Number Send Certificate To Send Invoice To I hereby certify that the information contained and submitted with this form is true and correct. Signature Date Printed Name Title The Iowa Department of Agriculture and Land Stewardship is an equal opportunity employer and provider.
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~-~ DEPARTMENT OF
~7::!:_RE
I
Iowa Department of Agriculture and Land Stewardship
Commercial Feed Bureau 502 E 9th St Des Moines IA 50319 Phone (515) 281-8597
A valid Iowa Commercial Feed License is needed before a certificate is issued.
ORDER FORM FOR CERTIFICATE OF FREE SALE
Feed Manufacturer Information
Name of Maufacturer Feed License Number Email
Street / PO Box City State Zip Code
Contact Person Direct Phone Fax
Product Name as It Should Appear on the Certificate Destination Country
Number of Products Per Certificate Number of Certificates Requested
X Fee Per Certificate = Total
Certificate of Free Sale X $ 35.00 = $
Departmental Seal X $ 10.00 = $
Notarized Affidavit X $ 35.00 = $
Feed Manufacturer/Dealer License Notarized X $ 10.00 = $
Good Manufacturing Practices Inspection (Inspection good for 2 years) X $ 2,744.37 = $
Total Number Enclosed Grand Total $
Requested Specialty Statement, if applicable.
Send Certificate by US MAIL FED EX OTHER Fed Ex Account Number
Send Certificate To Send Invoice To
I hereby certify that the information contained and submitted with this form is true and correct.
Signature Date
Printed Name Title
The Iowa Department of Agriculture and Land Stewardship is an equal opportunity employer and provider.
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