Maine Premises Identification Number Registration

Account Contact Information - Owner(s) of the Livestock

Primary Contact Name*:

Business Name:

Primary Phone Number*: Format 123-456-7890

Alternative Phone Number: Format 123-456-7890

Mailing Address*:

City*:

Zip Code*:

County*:
Select One Androscoggin Aroostook Cumberland Franklin Hancock Kennebec Knox Lincoln Oxford Penobscot Piscataquis Sagadahoc Somerset Waldo Washington York

Email:

Secondary Contact Name:

Secondary Contact's Phone Number: Format 123-456-7890

Premises Information & Details - Actual Location of Livestock

Name and/or Description of Premises*:

Physical Address of Premise (Street Address)*:

City*:

Zip*:

County*:
Select One Androscoggin Aroostook Cumberland Franklin Hancock Kennebec Knox Lincoln Oxford Penobscot Piscataquis Sagadahoc Somerset Waldo Washington York

Geographic Description of Premises

Township:

Latitude: (If known)

Longitude: (If known)

Premises Operation Type:

Select One Product Unit (farm or ranch) Clinic Exhibition Laboratory Market / Collection Point Non-Producer Participant Port of Entry Quarantine Facility Rendering

Livestock Head Count:

Please enter head count for each type of livestock on premises.

Bison:

Cattle - Beef:

Cattle - Dairy:

Chickens:

Deer/Elk:

Goats:

Horses:

Llama/Alpacas:

Other Poultry:

Rabbits:

Sheep:

Swine:

Other Livestock, Please list type and number: