Fill and Sign the General Form of Application for Warehouse License

General Form of Application for Warehouse License       (Name of Department or Agency) State of       (Name of State) The undersigned applies to       pursuant to the (Name of Department or Agency) provisions of       of       , (Citation of Statute) (Name of State) authorizing       to license and regulate the business (Name of Department or Agency) of public warehousemen, and under the rules of       , for (Name of Department or Agency) a license as public warehouseman for the license year commencing       . (Date) Included is a check or other draft to the order of to cover fees of $       as payment for a license to operate as a public warehouseman for the license year. The undersigned certifies that the following information is true to the best of the knowledge and belief of the undersigned: 1. Name of Business:       . (Name of Business) A. If corporation, give names of officers: 1. President:       . (Name of President) 2. Secretary:       . (Name of Secretary) 3. Treasurer:       . (Name of Treasurer) B. If partnership, give names and addresses of each partner: 1.       . (Name of First Partner) 2.       . (Name of Second Partner) 3.       . (Name of Third Partner) 2. Location of Business: A. Street address:       . General Form of Application for Warehouse License Page 1 of 3 Page 1 of (Street Address of Business) B. City:       . (Name of City) C. County:       . (Name of County) 3. State whether warehouse, elevator, or mill.       4. Type or types of commodities stored.       5. Total measured capacity:       (number of bushels or other measuring unit) 6. Capacity used for storage last year:       (number of bushels or other measuring unit) 7. General plan and equipment of building:             (description of general plan and equipment of building) 8. Name of building owner, if applicant is a lessee:       (name of building owner) 9. Operator of Business last year:       (name of operator) 10. Railroad on which building located, if any:       (name of railroad) 11. Proposed storage fees for license year :       cents per (Number)       (bushel/ (other measuring unit)) 12. Person or persons authorized to execute warehouse receipts:       13. Amount of bond: $       Name of surety:       (Name of Surety) 14. Net worth of applicant (estimated): $       15. Licenses held in other states, if any:                                     General Form of Application for Warehouse License Page 2 of 3 Page 2 of Dated:       (Date of Execution)       (Signature of Applicant)       (Type or Print Name) Approved by       (Name of Department or Agency) By: ____________________________________________ (Name and Signature) of official of department or agency)       (Title of official of department or agency) This license shall expire       (expiration date) General Form of Application for Warehouse License Page 3 of 3 Page 3 of