AH-CD-100N.docx (rev.10/16) Wisconsin Department of Agriculture, Trade and Consumer Protection REGISTRATION NO. Division of Animal Health Phone: (608) 224-4896 Fax (608) 224-4871 FARM-RAISED DEER KEEPER REGISTRATION APPLICATION For the Period Ending March 15, 2018 s. 95.55, Wis. Stats., s. ATCP 10.46, Wis. Adm. Code LEGAL NAME DBA, TRADE NAMES, OTHER NAMES USED TO CARRY OUT THIS BUSINESS: (LIST ALL) Individual Partnership Corporation LLC Trust Cooperative LEGAL ENTITY TYPE Other STATE BUSINESS IS FORMED IN: PRIMARY PHONE: WORK PHONE: MOBILE PHONE: FAX: ( ) - ( ) - ( ) - ( ) - MAILING ADDRESS STREET CITY STATE ZIP LICENSE CONTACT LICENSE CONTACT EMAIL CONTACT PHONE: WORK PHONE: MOBILE PHONE: FAX: ( ) - ( ) - ( ) - ( ) - OFFICERS (for Corp. or Coop), PARTNERS, MEMBERS (for LLC), OR TRUSTEES: NAME TITLE NAME TITLE NAME TITLE NAME TITLE LIST ALL OTHERS WITH LESS THAN 50% CERVID OWNERSHIP IN AN ANIMAL OR THE WHOLE HERD. (if a person owns 50% or more of any animal or 50% or more of the herd, that person must register separately as a farm-raised deer keeper.) Individual Partnership Corporation LLC Trust Cooperative Other STATE BUSINESS IS FORMED IN: LEGAL ENTITY/INDIVIDUAL NAME(S) PHONE: ( ) - LEGAL ENTITY/INDIVIDUAL MAILING ADDRESS STREET CITY STATE ZIP EMAIL WEB SITE WORK PHONE: MOBILE PHONE: FAX: ( ) - ( ) - ( ) - If a fawn under 12 months of age and not yet officially identified, indicate date of birth, sex and the ID of the mother. (Add additional sheets if necessary.) SIGNATURE: I certify that all information on this application and any attached sheets is true, accurate and complete. I certify by my signature that I am familiar with Wisconsin Administrative Codes and Wisconsin Statutes applicable to farm-raised deer in Wisconsin FARM-RAISED DEER KEEPER OR AUTHORIZED REPRESENTATIVE SIGNATURE DATE PRINT NAME OF PERSON SIGNING PRINT TITLE OF PERSON SIGNING
AH-CD-100N.docx (rev.10/16) Wisconsin Department of Agriculture, Trade and Consumer Protection Division of Animal Health Phone: (608) 224-4896 Fax (608) 224-4871 REGISTRATION NO. FARM-RAISED DEER KEEPER REGISTRATION APPLICATION For the Period Ending March 15, 2018 s. 95.55, Wis. Stats., s. ATCP 10.46, Wis. Adm. Code LEGAL NAME DBA, TRADE NAMES, OTHER NAMES USED TO CARRY OUT THIS BUSINESS: (LIST ALL) LEGAL ENTITY TYPE Individual Partnership Corporation LLC Trust Cooperative Other STATE BUSINESS IS FORMED IN: PRIMARY PHONE: ( ) - WORK PHONE: ( ) - MOBILE PHONE: ( ) - FAX: ( ) - MAILING ADDRESS STREET CITY STATE ZIP LICENSE CONTACT LICENSE CONTACT EMAIL CONTACT PHONE: ( ) - WORK PHONE: ( ) - MOBILE PHONE: ( ) - FAX: ( ) - OFFICERS (for Corp. or Coop), PARTNERS, MEMBERS (for LLC), OR TRUSTEES: NAME TITLE NAME TITLE NAME TITLE NAME TITLE LIST ALL OTHERS WITH LESS THAN 50% CERVID OWNERSHIP IN AN ANIMAL OR THE WHOLE HERD. (if a person owns 50% or more of any animal or 50% or more of the herd, that person must register separately as a farm-raised deer keeper.) Individual Partnership Corporation LLC Trust Cooperative Other STATE BUSINESS IS FORMED IN: LEGAL ENTITY/INDIVIDUAL NAME(S) PHONE: ( ) - LEGAL ENTITY/INDIVIDUAL MAILING ADDRESS STREET CITY STATE ZIP EMAIL WEB SITE WORK PHONE: ( ) - MOBILE PHONE: ( ) - FAX: ( ) - If a fawn under 12 months of age and not yet officially identified, indicate date of birth, sex and the ID of the mother. (Add additional sheets if necessary.) SIGNATURE: I certify that all information on this application and any attached sheets is true, accurate and complete. I certify by my signature that I am familiar with Wisconsin Administrative Codes and Wisconsin Statutes applicable to farm-raised deer in Wisconsin FARM-RAISED DEER KEEPER OR AUTHORIZED REPRESENTATIVE SIGNATURE DATE PRINT NAME OF PERSON SIGNING PRINT TITLE OF PERSON SIGNING
FRDKeeperRegistrationApp.docx