Milk Distributor Worksheet

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.).

Application Type

New Application

Renewal

*

License Number

D Validate License Number

Location Information

Same Information as Above

Prefix

required Select Mr. Mrs. Ms.

Last Name *

*

First Name *

*

Middle Initial

Suffix

required Select III IV Jr. Sr.

Business Name*

*

Address 1*

*

Address 2

City*

*

State*

Select Missouri Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *

County

required Select Adair Andrew Atchison Audrain Barry Barton Bates Benton Bollinger Boone Buchanan Butler Caldwell Callaway Camden Cape Girardeau Carroll Carter Cass Cedar Chariton Christian Clark Clay Clinton Cole Cooper Crawford Dade Dallas Daviess De Kalb Dent Douglas Dunklin Franklin Gasconade Gentry Greene Grundy Harrison Henry Hickory Holt Howard Howell Iron Jackson Jasper Jefferson Johnson Knox Laclede Lafayette Lawrence Lewis Lincoln Linn Livingston Macon Madison Maries Marion McDonald Mercer Miller Mississippi Moniteau Monroe Montgomery Morgan New Madrid Newton Nodaway Oregon Osage Ozark Pemiscot Perry Pettis Phelps Pike Platte Polk Pulaski Putnam Ralls Randolph Ray Reynolds Ripley Saline Schuyler Scotland Scott Shannon Shelby St. Charles St. Clair St. Francois St. Louis St. Louis City Ste. Genevieve Stoddard Stone Sullivan Taney Texas Vernon Warren Washington Wayne Webster Worth Wright

Zip Code *

Ext. - * x X

Primary Phone*

* x

Phone Type Select C-Cell H-Home O-Office * Ext.

Alternate Phone 1

* x

Phone Type Select C-Cell F-Fax H-Home O-Office * Ext.

Alternate Phone 2

* x

Phone Type Select C-Cell F-Fax H-Home O-Office * Ext.

Alternate Phone 3

* x

Phone Type Select C-Cell F-Fax H-Home O-Office * Ext.

E-mail Address

* x

Confirm E-mail Address

x email and confirm email do not match

Company Name and Labels to be Distributed for in the Coming Year

Company Name *

City*

*

State*

Select Missouri Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *

Label*

*

You must select ADD to populate the table for submission

Private Lables Field add to populate the table for submission

Company Name with Labels and Volume in Pounds of Milk Products Distributed in Missouri in the Previous Year

Company Name *

City*

*

State*

Select Missouri Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *

Label*

*

Pounds*

*

You must select ADD to populate the table for submission

Private Lables Field add to populate the table for submission