APPLICATION FOR INDIANA TIMBER BUYERS LICENSE |
CHECK ONE: New Application |
State Form 50313 (R3 / 6-16) |
Renewal of License |
Approved by State Board of Accounts, 2016 |
For License Year: ______________ |
Department of Natural Resources / Division of Forestry |
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Please complete entire application.
Questions Call 317/232-4105
Division of Forestry
(A)(I) (They) doing business as:
(Enter name of person, partnership or corporation to be licensed.)
With principal office located at: _______________________________________________________________________
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E-Mail Address |
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Telephone Number |
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If you are doing business as a Timber Buyer in a name other than your own, list that name:
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(B)If application is by a partnership, list partners or if application is by corporation, list principal officers and managing officer for Indiana.
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Is the corporation authorized to do business in Indiana? |
Yes |
No |
If so, submit a copy of Certificate of Admission or Incorporation. If you have already submitted a copy to us, please disregard this request. If the corporation is owned or controlled by another, give name and address:
____________________________________________________________________________________________
(C)Give the total dollars paid for timber (stumpage, logs, pulpwood, piling, veneer, etc.) bought from Indiana Timber growers (Government and Private) during the last calendar year or the last twelve (12) months
prior to this application: $*
*New buyers should estimate total dollar value to be paid for timber during the next twelve (12) months.
(D)CHECK ONE BELOW:
I am submitting a Surety Bond, Certificate of Deposit, or Cash Deposit with this application in the required amount.
My Surety Bond, Certificate of Deposit, or Cash Deposit is on file with your office in the proper amount.
I am submitting a “Rider” to my bond or an additional Cash Deposit to increase the amount of bonding to meet
the required amount for the new year.
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(E)Also, the one hundred fifty dollar ($150.00) Timber Buyer's License fee is enclosed.
(F)I am enclosing a total of __________________ dollars ($ ____________) for ________ (specify number) Agents. Attached to this application is one “Agent’s Registration” for each Agent I wish to register (including the owner or primary buyer). There is a twenty dollar ($20.00) registration fee for each agent you wish to register.
(G)The counties in Indiana which I propose to engage in the business of timber buying are as follows:
____________________________________________________________________________________________
(H)I hereby make application for a Timber Buyers License and do certify the information given is correct. I further certify that neither I nor any of the agents I am seeking to register herein have ever been convicted of a felony or a violation of Indiana Code 25-36.5-1-1 et seq., or any rule or regulation enacted by the Indiana Department of Natural Resources for the administration of these said laws.
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Applicant, Partner or Company Official (Print Name) |
Applicant, Partner or Company Official (Signature) |
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Date (month, day, year) |
Title |
(I)State of __________________
County of ________________
Being duly sworn upon this oath, deposes and says that he is the person who signed the above application and says that all statements in the above application are true, and said statements are made for the purpose of obtaining a Timber Buyers License in the State of Indiana.
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Notary Public Signature |
Notary Public Printed Name |
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Subscribed and sworn to before me, a Notary Public, in and said County and State this ______ day of |
__________________, ________. |
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My Commission Expires (month, day, year): __________________ |
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Check Enclosed |
Please make the Check / Money Order out to the |
Money Order Enclosed |
Department of Natural Resources. |
Credit Card – Expiration Date (month, year): ________ |
(CHECK ONE) |
Visa |
Master Card |
__________________________________________ |
_____________________________________________ |
PRINT name as it appears on Credit Card |
Card Number |
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Signature
Please enclose this slip with your application and all fees as prescribed in Indiana Code 25-36.5 and mail all to:
Indiana Division of Forestry, 402 W. Washington St., Room W296, Indianapolis IN 46204.