Alaska Raw Milk Producer Registration Application

Purpose of Application*

Farm Name*

Owner Name*

First NameLast Name

Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is the mailing address the same as the physical address?*

Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Email*

example@example.com

Animal Species (check all that apply)*

GoatCowSheep

Type of Sales (check all that apply)*

Direct to consumerMarket

List all markets where product is intended to be sold*

Type of Products (check all that apply)*

Cheese Types (list below)*

Type of Packaging (List product and describe packaging to be used. Example: raw milk - glass bottles; cheese - plastic wrap)*

Copy of Label 1

Copy of Label 2

Copy of Label 3

Copy of Label 4

Copy of Label 5

By checking the boxes below and signing, you are indicating agreement and compliance with the statement.

A copy of a label for each product type must be submitted with this application. If there are more than five labels needing to be submitted, please email the additional labels to akdairy@alaska.gov. I will attach a copy of a label for each product type with this application. I understand that failure to provide all required information may delay registration issuance.I understand that any changes including contact information, physical location, owner, animal species, type of sales, or products 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 or detention, 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.

After submission you will receive an email confirming the registration application has been received by the Office of the State Veterinarian. If you do not receive the email, resubmit your application or send an email to akdairy@alaska.gov.

Signature*

Date*

Please verify that you are human*