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

Application Type

License Type*

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

Owner Contact Options(s)

Receive license, renewal and correspondence by mail

Receive license, renewal and correspondence by email

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*

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

Location Contact Options(s)

Receive license, renewal and correspondence by mail

Receive license, renewal and correspondence by email

Milk Products Processor and/or Distributor Questionnaire

Does your milk Processor and/or Distributor business give or offer to give Missouri food retailers which it services any rebate, discount, free service or services?*

Rebate Discount

Explanation*

does your milk processor and/ or Distributor business give or offer to give missouri food retailers which it services any rebate, discount, free service or services?

Does your milk Processor and/or Distributor business give or offer to give Missouri food retailers which it services any advertising allowance?*

Advertising Allowance

Explanation*

does your milk processor and/ or distributor business give or offer to give missouri food retailers which it services any advertising allowance?

Does your milk Processor and/or Distributor business give or offer to give Missouri food retailers which it services payment for advertising space to be used jointly?*

Advertising Space

Explanation*

does your milk processor and/ or distributor business give or offer to give missouri food retailers which it services payment for advertising space to be used jointly?

Does your milk Processor and/or Distributor business give or offer to give Missouri food retailers which it services donations or free merchandise?*

Free Merchandise

Explanation*

does your milk processor and/ or distributor business give or offer to give missouri food retailers which it services donations or free merchandise?

Does your milk Processor and/or Distributor business give or offer to give Missouri food retailers which it services rent on space to be used by the retailer for storing or displaying your company's merchandise?*

Company Merchandise

Explanation*

does your milk processor and/ or distributor business give or offer to give missouri food retailers which it services rent on space to be used by the retailer for storing or displaying your company's merchandise?

Does your milk Processor and/or Distributor business give or offer to give Missouri food retailers which it services financial aid of any kind?*

Financial AId

Explanation*

does your milk processor and/ or distributor business give or offer to give missouri food retailers which it services financial aid of any kind?

Does your milk Processor and/or Distributor business give or offer to give Missouri food retailers which it services equipment on a free or less-than-market-value basis, either temporarily or as a permanent arrangement?*

Permanent Arrangment

Explanation*

does your milk processor and/ or Distributor business give or offer to give missouri food retailers which it services equipment on a free or less or less-than-market-value basis, either temporarily or as a permanent arrangement?

Does your milk Processor and/or Distributor business give or offer to give Missouri food retailers which it services any other item of value for which your company does not charge or receive the full, fair market value?*

Market Value

Explanation*

does your milk processor and/ or Distributor business give or offer to give missouri food retailers which it services any other item of value for which your company does not charge or receive the full, fair market value?

Do you anticipate that your marketing practices as described by your answers to questions 1 and 2 mentioned above will vary in the future use of your milk products Processor's and/or Distributor's license?*

Distributor License

Explanation*

Do you anticipate that your marketing practices as described by your answers to your questions 1 and 2 mentioned above will vary in the future use of your milk products processor's and / or Distributor's license?

Do you anticipate that your company will able to comply fully with the requirements of Sections 416.440, RSMo 2000, and the balance of the Unfair Milk Sales Practices Act?

Unfair Milk Sales

If you have any questions concerning the contents of this questionnaire, contact the Device and Commodity Inspection Program, telephone number (573) 751-5639.

Processor Payment

Total number of milk products, excluding cottage cheese, sold in Missouri during the 12-month period ending December 31 of the previous calendar year in pounds *

Rate

$0.01/hundredweight

Fee

Distributor Payment

Plant Name *

City*

State*

Fee $25.00

ValidateD istributorPayment

You must select ADD to populate the table for submission

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 05/29/2023

Milk Processor/Distributor License Application

You must select ADD to populate the table for submission