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

4203-003

08/13/2003

12/31/2004

FOR DIVISION USE ONLY:

FILE NUMBER:___________________

FEE:____________________________

ISSUE DATE:____________________

COUNTY:________________________

APPLICATION TO APPLY LEGUME INOCULANT

APPLICANT INFORMATION:

Applicant Name:

Applicant Address:

City, State, Zip:

County: Telephone: ( )

E-Mail Address: Fax Number: ( )

Website URL:

INOCULANT INFORMATION:

Name of crops for which the inoculant is applied:

Manufacturer's Name for each inoculant brand:

Process or technique used to apply inoculant to seed:

The undersigned agrees to the following:

1. To complete and return each individual registration with $5.00 application fee per individual registration.

2. To make Check or Money Order payable to Ohio Department of Agriculture. One check may be written with all locations combined.

3. 907.30 (B) (RC) The legume inoculator shall keep for a period of eighteen months, records which shall include complete data concerning the sources and lot numbers of the inoculant meterial used, the rate and date of application and the lot identity by owner and lot number, if any, of the seed to which the material was applied.

I certify that all information provided on this application is correct to the best of my knowledge.

Signature of Applicant

Date

Printed Name

Title