Approved Conditioner /Bulk Retail Facility Application Form

Name of Conditioning Plant
Address of Conditioning Plant Address of Conditioning Plant
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Telephone Number Telephone Number - ### - ### ####
Cell Number Cell Number - ### - ### ####
Fax Number Fax Number - ### - ### ####
Email Address
Coordinates to plant: Longitude
Coordinates to plant: Latitude
The person in this plant who will supervise the conditioning operations and who will be
assigned the responsibility of complying with the provisions of the regulations. The person in this plant who will supervise the conditioning operations and who will be
assigned the responsibility of complying with the provisions of the regulations. First Last
List below all the equipment that is available and suitable for use in the conditioning of the Oklahoma Certified seed. State kind, model and size of all factory-made equipment. Be sure to list bins, seed cleaners, scarifiers, seed treaters,etc
Check each of the following certified crop(s) that you intend to process under the rules and regulations as an Approved Conditioner.

Check each of the following certified crop(s) that you intend to process under the rules and regulations as an Approved Conditioner. Alfalfa Barley Clover Cotton Cowpeas Grasses Guar Lespedeza Millet Mungbean Oats Peanuts Rye Soybeans Sudan Vetch Wheat
I hereby make application for approval as an Approved Conditioner/Bulk Retail Facility of Oklahoma Certified seeds at the plant named as described above. I read the regulations entitled “Handbook for Oklahoma Approved conditioners of Certified Seed,” and hereby express the willingness of this firm to abide by these regulations. I am enclosing $75.00 as a conditioning plant fee.
Draw or type your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Title
For OCIA Personnel Only
Date application received Date application received / MM / DD YYYY
Amount of fee paid $ Dollars . Cents
Date Inspection made Date Inspection made / MM / DD YYYY
Inspection made by Inspection made by First Last
Certificate sent

Approved Conditioner /Bulk Retail Facility Application Form

For OCIA Personnel Only