Milk Hauler Slicense Renewalapplication

PMMB-77

Rev. 04/18

Commonwealth of Pennsylvania

MILK MARKETING BOARD

2301 North Cameron Street – Room 110

HarrisburgPA 17110-9408

Website:

Phone: 717-787-4194 Fax: 717-783-6492

MILK HAULER’SLICENSE RENEWALAPPLICATION

Licensing year:July 1, 2018 - June 30, 2019

Application due: on or before June 15, 2018

fixed fee - $30.00

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PLEASE PRINT OR TYPE:

License Number______

Business or Trade Name: ______

Contact Person: ______

Phone: ______Fax: ______

Mailing Address: ______

(Street) (County)

______

(City) (State) (Zip code)

Email Address:______

Web Address: ______

If an entity, state and date established:______

Were you ever licensed by the PA Milk Marketing Board as a Milk Hauler? Yes______No ______

Do you pick up milk at farms? Yes______No______

List the name and license number of each Pennsylvania weigher/sampler employed or otherwise utilizedby applicant.

(Use additional paper, if necessary.) THIS APPLICATION WILL BE RETURNED IF THIS SECTION IS NOT COMPLETED.

Name License # Name License #

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______

______

______

List the names and locations of all Dealers for whom applicant is hauling milk or cream.

(Use additional paper, if necessary.)

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______

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PLEASE SIGN APPLICATION ON REVERSE SIDE.

A hauler’s license fee of thirty dollars ($30.00), which can be paid by check or money order, payable to the “Commonwealth of Pennsylvania”, must accompany this application.

If at any time during the licensing period there is a change to any information contained in this application, please notify the Milk Marketing Board. If you should discontinue operating as a hauler, please notify the Milk Marketing Board in writing, and return your hauler’s license.

“Application is hereby made for a Milk Hauler’s License under the provisions of the Pennsylvania Milk Marketing Law. The undersigned hereby affirms that the foregoing information is true and correct to the best of my knowledge, information and belief, and is made subject to the penalties prescribed by 18PA.C.S.Section 4904 (relating to unsworn falsification to authorities).”

signature______date______

Type or print name and title: ______

• The PMMB-79 Milk Hauler’s Report must be completed and filed with your hauler feemonthly. This report identifies the prior month’s hauling activity and must be filed on or before the 30th of each month. A report is required even if there is no activity to report. Failure to comply with this filing requirement may be subject to possible legal referrals.

• In addition to the annual fixed fee of $30.00, all licensed Milk Haulers shall pay the sum of $.005 per hundred weight on all milk hauled, computed as follows:

There is a $20.00 service charge for any returned checks.

Any questions please contact Fatima Roberge at 717-836-3114 or email