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Iowa Department of Agriculture & Land Stewardship (IDALS)

Commercial Feed Bureau 502 E 9th St Des Moines IA 50319 Phone (515) 281-8597

A valid Iowa Commercial Feed License is needed before a certificate is issued.

ORDER FORM FOR CERTIFICATE OF FREE SALE

Feed Manufacturer Information

Name of Maufacturer Feed License Number Email

Street / PO Box City State Zip Code

Contact Person Direct Phone Fax

Product Name as It Should Appear on the Certificate Destination Country

Number of Products Per Certificate Number of Certificates Requested

X Fee Per Certificate = Total

Certificate of Free Sale X $ 35.00 = $

Departmental Seal X $ 10.00 = $

Notarized Affidavit X $ 35.00 = $

Feed Manufacturer/Dealer License Notarized X $ 10.00 = $

Good Manufacturing Practices Inspection (Inspection good for 2 years) X $ 2,744.37 = $

Total Number Enclosed Grand Total $

Requested Specialty Statement, if applicable.

Send Certificate by US MAIL FED EX OTHER Fed Ex Account Number

Send Certificate To Send Invoice To

I hereby certify that the information contained and submitted with this form is true and correct.

Signature Date

Printed Name Title

The Iowa Department of Agriculture and Land Stewardship is an equal opportunity employer and provider.