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 *

zip plus four -

Primary Phone *

Phone Type Ext.

Alternate Phone 1

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 *

zip plus four -

Primary Phone *

Phone Type Ext.

Alternate Phone 1

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

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. Required

Legal Name*

Date 04/21/2026

Milk Processor/Distributor License Application