Premises Identification Voluntary Entry Contact information will not be sold or given out without your written consent. Business/ Farm Name: Business/Farm Name Owner Information: First Name Middle Initial Last Name Secondary Contact Information: First Name Middle Initial Last Name Business/Farm Mailing Address: Address Line 1 Address Line 2 Mailing Zip Mailing City Mailing State County Contact Information: Business Phone Cell Phone Home Phone Primary Contact Email Alternate Email Operation Type: (Check ALL that apply) Producer Unit/Farm Clinic Exhibition Laboratory Market/ Collection Point Non-Producer Participant Slaughter Plant Tagging Site Premises Information: Primary location where livestock resides. If more than one location and animals managed separately, apply for multiple premises ID's Premises Address: (Must be a 911 address) Same as business/farm mailing address. If not, complete address below Address Line 1 Address Line 2 Premises Zip Premises City Premises State Species at premises: (Check ALL that apply) Beef Cattle Dairy Cattle Bison Swine Deer /Elk Llama Sheep Goats Equine Poultry Feedmill Hatchery Other Specify Submit Reset