Alaska Raw Milk Market Registration Application
Alaska Department of Environmental Conservation, Division of Environmental Health, Office of the State Veterinarian
Purpose of Application
*
Please Select
New Application
Annual Renewal
Update Previous Application
Market Name
*
Food Safety & Sanitation Permit ID
*
Office of State Veterinarian Registration Number for Raw Milk Producer(s) product(s) you intend to sell:
*
Owner
*
First Name
Last Name
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is the mailing address the same as the physical address?
*
Please Select
Yes
No
Mailing Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Owner's Email
*
example@example.com
Owner's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Market's Email
example@example.com
Market's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is the owner the same as the manager/main contact person of the market?
*
Please Select
Yes
No
Manager/Main Contact Person
*
First Name
Last Name
Manager/Main Contact Person's Email
example@example.com
Manager/Main Contact Person's Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
By checking the boxes below and signing, you are indicating agreement and compliance with the statement.
*
I understand that failure to provide all required information may delay registration issuance.
I understand that any changes including contact information, physical location, owner, or manager require a new registration form to be completed and marked as an update to previous application.
I certify that I have read and understand the Raw Milk and Raw Milk Products Production and Sales regulations (18 AAC 32.070).
I certify that I am in compliance with the requirements necessary to sell raw milk and/or raw milk products in accordance with these regulations (18 AAC 32.070).
I certify that I will continue to meet the requirements as long as I hold registration to operate under those regulations.
I further understand that failure to meet these requirements may result in my registration being revoked, forfeiting the authorization to sell raw milk and raw milk products, the department ordering a product recall, and/or the department issuing an order to stop sale.
I understand that I am responsible for complying with all applicable local, state, and federal regulations.
Signature
*
Date
*
-
Month
-
Day
Year
Please verify that you are human
*
Submit
Should be Empty: