MDA Webforms | Livestock-Dealer-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.).

Applicant Information

Prefix

Last Name *

First Name *

Middle Initial

Suffix

Business Name

Address 1*

Address 2

City*

State*

County

Zip Code *

Ext. -

Primary Phone*

* x

Phone Type * Ext.

Alternate Phone 1

* x

Phone Type * Ext.

Alternate Phone 2

* x

Phone Type * Ext.

Alternate Phone 3

* x

Phone Type * Ext.

E-mail Address

Confirm E-mail Address

Business Information (Check All That Apply)

select atleast one type of livestock

Type of Livestock (Choose at least one)

Cattle

Swine

Equine

Exotic Animals

Sheep

Goats

Poultry

Cervidae

Trade Area

Validate Trade Area

IntraState

InterState

Agent Information

Last Name*

First Name*

Middle Initial

Address 1*

Address 2

City*

State*

Zip Code *

Ext. -

Primary Phone*

* x

Phone Type * Ext.

E-mail Address

Confirm E-mail Address

Bond Information

Bonded by packers and stockyards

Yes

Bond Number*

validate number

Signature

By signing this application I acknowledge that I am aware of my responsibilities as outlined in 2 CSR 30-7.010 Provisions for Registration and Recordkeeping of Livestock Dealers and 276.600 – 276.661, RSMo, 2000, Missouri Livestock Dealer Law, and further agree to comply with all animal health laws and regulations pertaining to the movement of animals, animal well-being and procedures used for the control of disease.

Legal Name*

Date 11/21/2024

Livestock Dealer Application