To The Department of Livestock Brands Enforcement Division Administrator:

I hereby state that I am fully aware and I do willingly accept full responsibility for all transactions, financial or otherwise, made or entered into, by the following person(s) while acting as an agent for me. I will inform the following agents listed below that they will conduct all transactions under the name of the Entity to be licensed as listed on page 1, part 1. Furthermore, I will send all required information to the Packers & Stockyards Administration (at the times required by Packers & Stockyards) concerning the activities of all agents so that the bond amount for the entity (as listed on page1, part 1) can be determined correctly.

Livestock Dealer Agents: A licensing fee is required for each Livestock Dealer Agent

Name of Agent Agent Type (Owner, Co-Owner, Agent, Employee, Clearee, Independent Contractor) Mailing Address & Phone Number

All information, concerning the agents listed above, is required to process their license

Printed Name of Licensed Dealer: ___

Signed: ___

Date: ___

(from page 1, part 1 – Owner, Partner, or Responsible Officer)

(from page 1, part 1 – Owner, Partner, or Responsible Officer)