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OHIO DEPARTMENT OF AGRICULTURE

Division of Plant Industry - Grain & Seed Section

8995 East Main Street

Reynoldsburg, OH  43068-3399

(614) 728-6410

DIVISION:

Web FORM:

Last Revised:

FORM EXPIRES:

PLNT-GS

4203-001

08/13/2003

12/31/2003
 

AGRICULTURAL COMMODITY HANDLER LICENSE APPLICATION

 

CONTACT GRAIN WAREHOUSE OFFICE BEFORE FILING THIS FORM!
 

R.C. 926.05 (a) states that each person or company desiring to renew a handler's license shall file an application annually with Ohio Department of Agriculture.

 

R.C. 926.05 (e) states that the renewal application must be filed 30 days PRIOR to the expiration of the current license to avoid a late penalty.  The minimum penalty is $15.00.

 

After contacting the Grain Warehouse Office, complete each step of the application and return to Ohio Department of Agriculture promptly.  Use additional sheets as needed or write on the back of this application.

 

 

Company Name:
Mailing Address: Physical Address:
City:                                                                   State:                     Zip Code:                             County:
Telephone: General Manager, or Contact:
Fax: E-Mail Address:
 

Business Operation Type:  Proprietorship   Partnership   Corporation   Cooperative   Other
If "Other", explain:

 

 

What is the closing date of your operating year?

Certified Public Accountant:
Mailing Address:
City:                                                                   State:                    Zip Code:                             County:
Telephone: Contact Person:
Fax: E-Mail Address:
 

List names, mailing addresses, and telephone numbers of owners, partners, or corporate officers and Ohio Statutory Agent of the applying company:

Company Officer

 Name Mailing Address Telephone
President      
Vice President      
Treasurer      
Secretary      
Ohio Statutory Agent      
       
       

 

 

 

 

 

Does your company lease any of its grain facilities?     Yes    No       If Yes, please provide a current lease agreement.
Insurance Agent Name:
Mailing Address:
City:                                                                   State:                    Zip Code:                             County:
Telephone: Contact Person:
Fax: E-Mail Address:

 

 

 

List names, mailing addresses, telephone numbers, and contact person from each financial institution that your company conducts business.  List the type of accounts maintained for you by each institution listed (ie:  checking, savings, loans, credit lines, etc.).

Financial Institution

& Contact Person

 Type of Account Mailing Address Telephone
       
       
       
       
       
       
       
       

 

 

List names, addresses, telephone numbers, and contact person from each grain broker that your company utilizes:

Grain Broker

 Contact Person Mailing Address Telephone
       
       
       
       
       
       
       
       

 

 
Check the services that your company provides to its customers:
Business Operation Type:  Cash Purchase/Sale   Grain Bank   Open Storage  Delayed Price   Other
If "Other," please list:

 

 

What are your hours of operation?*
Day SUN MON TUE WED THU FRI SAT

Hours

              
* Please keep in mind that our examinations are unannounced, therefore, you must select at least one day per week that someone who can provide grain records will be available.  Also, please note any special times or dates that your company will be closed, or call the Department of Agriculture at least five working days in advance.  If the Ohio Department of Agriculture arrives to do an examination and your company is closed or the required staff is not available, your company will be charged for a return examination.

 

 

 

Please list the following information for each of your licensed facilities:

Facility Locations

Branch Manager

Telephone

Storage Capacity (bu.)

Railroad Serving Facility

Siding Size

 (Cars)

Truck Sale Capacity (Tons)

   1.  MAIN:

 

 

 

 

 

 

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 12.

 

 

 

 

 

 

 

 

 Does your company use computerized grain software?  Yes   No       If Yes, please provide the following:

Vendor Name

Contact Person

Vendor Address

Telephone

 

 

 

 

 

 

Has the applicant ever pled guilty to, or ever been convicted of any felony or charge of embezzlement under the laws of this state, any other state, or of the United States?  If so, explain:

 

 

The applicant, as a condition to the granting of an agricultural commodity handler license, agrees to comply with and abide by the terms of Chapter 926 of the Revised Code and the rules adopted there under, so far as the same may relate to him/her.  The statements made in the forgoing are hereby certified to be true, accurate, and complete to the best of my knowledge.

 

 

Signed:

Date:

 

Print Name:

Title:

 

 

PLEASE KEEP IN MIND THAT ALL BLANKS MUST BE FILLED IN ON THIS FORM.

If any step does not apply to your business, please place an "N/A" in the space provided.  Failure to complete the application to its entirety may result in rejection of the application.  If you have any question, please feel free to call me at (614) 728-6410.  Thank you for your cooperation.

 

David K. Simmons

Agriculture Inspection Manager