Missouri Egg License Application

Please DO NOT include any personal, confidential, and/or sensitive information in your responses on this form (e.g. social security number, credit card information, health information, account number, etc.).

Owner Information

Prefix

Last Name *

First Name *

Middle Initial

Suffix

Business Name*

Address 1*

Address 2

City*

State*

County*

Zip Code *

Ext. -

Primary Phone*

Phone Type Ext.

Alternate Phone 1

Phone Type Ext.

Alternate Phone 2

Phone Type Ext.

Alternate Phone 3

Phone Type Ext.

E-mail Address

Confirm E-mail Address

Missouri Tax ID #*

Owner Contact Option(s)

Check one or both*

Receive license, renewal and correspondence by mail
Receive license, renewal and correspondence by email

Store Location Information

Same Information as Above

Prefix

Last Name *

First Name *

Middle Initial

Suffix

Business Name*

Address 1*

Address 2

City*

State*

County*

Zip Code *

Ext. -

Primary Phone*

Phone Type Ext.

Alternate Phone 1

Phone Type Ext.

Alternate Phone 2

Phone Type Ext.

Alternate Phone 3

Phone Type Ext.

E-mail Address

Confirm E-mail Address

Upload No Tax-Due Statement

If you are applying for a Retailer (R1) Egg License, upload your no tax-due statement.
Without this statement, your egg license will be delayed until tax compliance can be confirmed.

Upload Name
JPEG , JPG , PDF

Signature

I certify this information is correct

Legal Name*

Date 09/26/2023

Missouri Egg License Application

If you are applying for a Retailer (R1) Egg License, upload your no tax-due statement. Without this statement, your egg license will be delayed until tax compliance can be confirmed.

If you are applying for a Retailer (R1) Egg License, upload your no tax-due statement.
Without this statement, your egg license will be delayed until tax compliance can be confirmed.