Fill and Sign the George Mangiaracina Memorial Scholarship Application Form

IDAHO STATE DEPARTMENT OF AGRICULTURE WAREHOUSE CONTROL PROGRAM 2270 OLD PENITENTIARY ROAD PO BOX 790 BOISE, ID 83701 (208) 332-8660 12-04 Application for Seed Buyer License Renewal of Seed Buyer License Amount Received License No. The applicant, as a condition of receiving a license, agrees to comply with and abide by the terms of Title 22, Chapter 51, Idaho Code and rules thereunder. Upon suspension, revocation or expiration of a Seed Buyer license, the licensee shall return the Seed Buyer license to the Idaho State Department of Agriculture. 1. Business name: 2. Principal business mailing address: 3. Business phone No.: 5. Business mailing address in Idaho: 6. Idaho phone No.: 8. The applicant is an: 4. Fax No.: 7. Idaho Fax No.: Individual 9. Partnership Corporation Limited Liability Company ( L.L.C.) Parent company (if applicable) : 10. Parent company principal business mailing address: 11. Parent company phone No.: 12. Fax No.: 13. Business location(s) address in Idaho: County: County: County: County: INDIVIDUAL 14. If an Individual, list name and address: PARTNERSHIP 15. If a Partnership, list names and addresses of partners : 16. If this application is for an Individual or a Partnership, has your business or firm name been recorded with the Office of the Secretary of State? Yes No 17. If a Corporation, use the true corporate name as shown in your Articles of Incorporation. Corporation Name: 18. If a Limited Liability Company, use the Limited Liability Company (L.L.C.) name as shown in your Articles of Incorporation. Limited Liability Company: Page 1 SIF-12-04 CORPORATION or LIMITED LIABILITY COMPANY 19. If a Corporation or Limited Liability Company (L.L.C.), list name and business address of officers and registered agent. President or CEO address Vice President address Secretary address Treasurer or CFO address General Manager address CEO address Registered Agent address 20. If this application is for a Limited Liability Company (L.L.C.), has your business or firm name been recorded with the Office of the Secretary of State? Yes No 21. Designate the State and date the Corporation or Limited Liability Company (L.L.C) papers were filed: State Date 22. Does the applicant currently have in effect a Seed Dealer license pursuant to Title 22, Chapter 4, Idaho Code "Pure Seed Yes (License Number): No Law"? 23. Does the applicant or any of the individuals named above in questions #14, #15 and # 19, currently have in effect a Seed Buyer's bond or Irrevocable Letter of Credit? Yes No 24. If the answer to question #23 above is yes, has a claim been ordered collected or actually been collected against the bond or Irrevocable Letter of Credit pursuant to Title 22, Chapter 51, Idaho Code? Yes No 25. Does the applicant or any of the individuals named above in questions #14, #15 and #19 have a current "commercial property policy" of insurance pursuant to Title 22, Chapter 51, Idaho Code, "Seed Indemnity Fund Law." Yes No 26. Have there been any legal judgments against the applicant's business in the past three years? If yes, provide an Yes No explanation and attach. 27. Has the applicant or any of the individuals named above in questions #14, #15 and #19 been convicted of a felony? Yes No 28. Does the applicant have any outstanding producer financial obligations? Yes If yes provide detailed amounts and attach. No 29. The applicant's fiscal year ends: 30. Name and address of banks(s) that handle the applicant's business accounts(s). By my signing below, I certify that I have thoroughly read and fully understand and will abide by the provisions of Title 22, Chapter 51, Idaho Code, and rules thereunder of the Idaho State Department of Agriculture. I further certify that all answers and statements on this application are true and complete to the best of my knowledge. I understand that should an investigation disclose untruthful or misleading answers, my application may be rejected and any Seed Buyer license issued to me pursuant to Title 22, Chapter 51, Idaho Code, may be canceled at any time. Name (print): Position: Signature: Page 2 SIF-12-04 Date: