Oregon Department of Agriculture, Food Safety Division, (503) 986-4720
LICENSE EXPIRES JUNE 30, ___________
PRINT OR TYPE
Legal Name (Owner) __ ___
Attn/Contact Name __________________________________________________
Mailing Address_____________________________________________________
City,State,Zip_______________________________________________________
Phone No _______________________ Fax No______________________ E-mail _________________________________________
Separate Fee is Required For Each License Type FEE
FEE PAID
_ ____ 08 Refrigerated Locker Plant (RLP)
$100.00
$_____________
Half Year Rate (after January 1)
$50.00
$_____________
FEE
FEE PAID
_ ____ 13 Egg Handler* (EHP)
$25.00
$_____________
_ ____ 14 Egg Breaker (EBP)
$75.00
$_____________
Late Penalty Fee ** see back $_____________
TOTAL FEES SUBMITTED $___________
*How many dozen eggs per week do you estimate your facility will produce ____________ dozen per week
*SMALL FLOCK EXEMPTION CLAIM
The above named facility produces an average of 100 dozen eggs or less per week and qualifies for the small flock millage fee
exemption. I understand if our average sales of eggs increase and regularly exceed an average of more than 100 dozen eggs per
week, ODA must be notified, and payment of millage fee will be required.
____________________________________________________________
Signature Date
If you are a licensed producer out of the state of Oregon please provide your permit and/or plant number _____________
Owner’s Signature ________________________ ___ _____ Title _____________________________________
License is personal to the applicant and cannot be transferre