Registrant company numbers: Registered for: ________________ Registered by: ________________ Tonnage reported by: __________ Audit Code: __________ 3 APPLICATION FOR REGISTRATION OF SPECIALTY FERTILIZERS IN KENTUCKY (Packages of 10 pounds or less) Mail completed application to: Fertilizer Regulatory Program 103 Regulatory Services Building - Lexington, KY 40546-0275 Phone: 859-257-2785 Fax: 859-257-9478 Web: www.rs.uky.edu Application is hereby made for the registration of the brands and grades of fertilizers listed below for the period ending December 31, 20_____. We agree that the company name and address appearing after the “REGISTERED FOR” will be printed on each invoice associated with the fertilizer and upon approval of this application said company assumes full responsibility for compliance with all the requirements of the Kentucky Fertilizer Law and Regulations. Labels MUST be attached for each brand and grade for which registration is requested. NEW PRODUCT REGISTRATION ONLY Registered FOR: ________________________________ Address ___________________________________________ City, State, Zip _________________________________ Registered BY: _________________________________ Address ___________________________________________ City, State, Zip _________________________________ Tonnage REPORTED BY: __________________________ Address __________________________________________ City, State, Zip _________________________________ Date ___________ Signature ________________________________________________ _____________________________________________________________________ (Printed name and title) Phone __________________________________ Fax __________________________________ Email _________________________________________________________ Brand Name and Grade of Fertilizer or Fertilizer Material Net Weight of Packages (≤10 LBS.) GUARANTEED ANALYSIS N K2O P2O5 * List ID numbers for labels of products in this column if they are labeled DO NOT SEND MONEY WITH APPLICATION you will be invoiced when registrations are approved. Please do not write below this line – for use by Division of Regulatory Services Secondary and/or Micronutrients ID/Label#* Registration Fee $50.00 & Annual Inspection Fee $50.00 SUB-TOTAL FEES _____RENEWALS@$100.00 EA. TOTAL FEES DUE Please do not write in this space – Reserved for Division of Regulatory Services office use Check Amount _____________________ Check Number ________________________ Date of Check __________________ Date Received_________________ RS23 - 2014
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