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

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.

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

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.

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

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

Fee $25.00

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/Distributor License Application