MDA Webforms | Milk-Processor-Application-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.).

Owner 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

Plant Location Information

Use 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*

* 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

Pounds Exempt From License Fee

Gross pounds of raw milk purchased in the previous calendar year *

Pounds used to manufacture ice cream, cheese, cottage cheese, dry milk, and other milk products not included in the definition of "milk products". This figure need not be itemized as to products:*

Pounds of milk spoiled or wasted *

Pounds of milk sold outside Missouri. Specify as to state of sale

Pounds

Check Pounds Field

You must select ADD to populate the table for submission

Pounds of milk products (as defined in Rule 90.38.010(12)) sold in Missouri

Total Milk Sold

All Private Labels Which You Package For Missouri Sales

Company Name

City

State

Label

You must select ADD to populate the table for submission

Private Lables Field

List Distributors Trafficking Your Product in Missouri

Distributor

City

State

You must select ADD to populate the table for submission

Private Lables Field

Signature

I/We the undersigned, do hereby swear (or affirm) that the above information supplied by me/us is true and correct and that all provisions of the Missouri Unfair Milk Sales Practices Law as amended or revised and related regulations will be strictly adhered to.

Legal Name*

Date 11/21/2024

Milk Processor Worksheet

You must select ADD to populate the table for submission

You must select ADD to populate the table for submission

You must select ADD to populate the table for submission