Texas Form Reg 200 – Fill Out and Use This PDF

SECTION A

SECTION B

	New Business	Change of Ownership – previous account number:
	2 BUSINESS TYPE				TDA USE ONLY
	Corporation	Sole Proprietorship			Client No.				Account No.
	Limited Liability Co.	Government
	Limited Partnership	Organization
					Date (mm/dd/yy)				Initials
	General Partnership

3CLIENT INFORMATION

Full legal business name (owner’s name if sole proprietor – no aliases)

D.B.A. (if applicable)

Comptroller Taxpayer ID No.(In-state businesses only) Federal Taxpayer ID No. (Out-of-state businesses only)

SOLE PROPRIETORSHIP ONLY

Social Security No. (SSN - Required)		If you do not have an SSN you must a attach form Affidavit for
-	-	Occupational License - No Social Security Number (OGC-001)
		available at http://www.agr.state.tx.us
Driver License No. ____________________ (if SSN is not available)				TX
State Issued ID No. ____________________ (if DL is not available)				Other

1RESPONSIBLE PERSON INSTRUCTIONS

Please list the full legal name (no aliases or nicknames) of the primary person responsible for the business, as indicated:

For a corporation, limited liability company, or cooperative, the president or CEO,

For a limited or general partnership, the managing partner or general manager,

For a sole proprietorship, the owner,

For any other type of business, the general manager.

2RESPONSIBLE OFFICER, PARTNER, MANAGER, OR OWNER

First Name				M. I.	Last Name
Phone No.					E-mail
(	)	-	Ext.

City

State

Zip

SECTION D

2PHYSICAL ADDRESS OF LOCATION OF LICENSEE, LICENSED ACTIVITIES OR EQUIPMENT

Address (No P.O. Box)

City	State	Zip	County

Directions to Physical Location if address above is difficult to find

SECTION E

1OUT-OF-STATE APPLICANTS ONLY

An applicant for an Egg license whose principal place of business is situated outside the State of Texas must appoint and designate a resident citizen of Texas as said applicant’s resident agent within Texas. This information is REQUIRED if the address provided in Section C is out of state.

Who do you wish to designate as resident agent? The Texas Secretary of State Other (list below) Resident Agent Name

Resident Agent Address

City	Zip	Business Phone
		(	)	-

SEC. F

SECTION G

1BUSINESS CLASSIFICATION

Dealer-Wholesaler – Complete Section G, #1

Processor – Complete Section G, #2

Broker ($420) – Please skip to Section H

Retailers selling eggs directly to consumers are not required to obtain a license.

1DEALER-WHOLESALER CLASS

Are you a packer?			Yes	No
If yes, please provide USDA Plant No. (if applicable) ________________________
Estimated Average Weekly Volume (check only one)
Class 1	($20)	– 1 case (30 dozen eggs) or more, but less than 10 cases
Class 2	($40)	– 10 cases or more, but less than 50 cases
Class 3	($60)	– 50 cases or more, but less than 100 cases
Class 4	($100) – 100 cases or more, but less than 200 cases

Class 5 ($180)		– 200 cases or more, but less than 500 cases
Class 6 ($270)		– 500 cases or more, but less than 1,000 cases
Class 7	($360) –		1,000 cases or more, but less than 1,500 cases
Class 8	($720) –		1,500 cases or more, but less than 3,000 cases
Class 9	($900) –		3,000 cases or more, but less than 4,500 cases
Class 10 ($1200)			– 4,500 cases or more, but less than 7,000 cases
Class 11 ($1800)			– 7,000 cases or more, but less than 10,000 cases
Class 12 ($2400)			– 10,000 cases or more

2PROCESSOR CLASS

Estimated Average Weekly Volume (check only one)

Class 1	($60) – Less than 250 cases per week
Class 2	($120)	– 250 cases or more, but less than 600 cases
Class 3	($210)	– 600 cases or more, but less than 1,500 cases
Class 4	($420)	– 1,500 cases or more

SECTION H

SECTION I

SECTION J

1PAYMENT

Please see instructions for applicable fees.

REGISTRATION IS NOT VALID UNTIL APPROVED BY TDA.

Method of Payment

(payable to Texas Department of Agriculture)

Check #

Cashier’s Check #

Money Order #

Amount remitted

Mail to: Texas Department of Agriculture

$

P.O. Box 12076, Austin, TX 78711-2076

TDA USE ONLY

Receipt No.

Date Receipt Issued

1SIGNATURE

The applicant, by and through their personal or agent's signature below (1) certifies that all information provided in connection with this application at any time is true and correct to the best of the applicant's knowledge; (2) acknowledges that any misrepresentation or false statement made by the applicant, or an authorized agent of the applicant, in connection with this application, whether intentional or not, will constitute grounds for denial, revocation, or non-renewal of any license issued pursuant to this application and/or assessment of monetary administrative penalties; and (3) if applying as an individual, further acknowledges that this application may be denied and that any license issued pursuant to this application may be suspended, revoked, or denied renewal due to delinquency in payment of a guaranteed student loan and that any license issued pursuant to this application may be suspended or denied renewal for failure to pay child support. If signed by an agent (including employee) of the applicant, the person signing certifies that he or she is authorized to make the preceding certifications on behalf of the applicant.

Applicant Name	Title
Applicant Signature	Date	/	/
	month	day	year

1CHECKLIST

Please use this checklist to ensure you are sending all of the necessary information and documents.

Egg License Application

Fee (see instructions for assistance with calculating the correct fee.)

Please note that an incomplete application may result in processing delays.