Premises Registration Form

* indicates a required field

1. Animal Housing Location

Address *
City *
State *
Zip code *
County *
Township *
Number of Houses *

2. Primary Contact (Correspondence and Emergency)

Name *
Address
City
State
Zip code
Home Phone  *
Business Phone
Cell Phone
Fax
Email  *

Check all that apply:

Land Owner
Manager
Animal Owner
Other
 

3. Secondary Contact (Correspondence and Emergency)

Name *
Address
City
State
Zip code
Home Phone  *
Businss Phone
Cell Phone
Fax
Email  *

Check all that apply:

Land Owner
Manager
Animal Owner
Other
 

4. Domestic Species at this location? Check all that apply & provide animal count

DairyCattle

DairyCattle > Milking Herd
DairyCattle > Heifer Grower
DairyCattle > Veal Grower
DairyCattle > Other
BeefCattle

BeefCattle > Cow/Calf
BeefCattle > Backgrounder
BeefCattle > Feedlot
BeefCattle > Other
Swine

Swine > Grower
Swine > Nursery
Swine > Finisher
Swine > Other
Sheep  **
Goats  **

Goats > Dairy
Goats > Meat
Goats > Other
Camelids

Camelids > Alpacas
Camelids > Llamas
Camelids > Other
Cervids

Cervids > Deer
Cervids > Elk
Cervids > Other
Equine (Horse,Donkey,Zebra, etc.)
Turkeys
Waterfowl
Ratite
Upland Game Birds
Pigeons
Chickens

Chickens > Egg
Chickens > Meat
Chickens > Other
Other Domestic Species
 
** If you have a USDA Scrapie ID please list
Enter the characters you see in the picture *