REG3 by HC76e9e9f310aafbe4d8ddaa6bbf8ef0c7


                                                 FOR SPECIALTY FERTILIZERS IN PACKAGES OF 10 POUNDS OR LESS
                                              APPLICATION FOR REGISTRATION OF SPECIALTY FERTILIZERS IN KENTUCKY                                              UNIVERSITY OF KENTUCKY
   College of Agriculture                                                       Mail Completed Application to:                                                  College of Agriculture
   Division of Regulatory Services                                        Coordinator, Fertilizer Regulatory Program                                            Division of Regulatory Services
   An Equal Opportunity University                                103 Regulatory Services Building - Lexington, KY 40546-0275                                   An Equal Opportunity University

  Application is hereby made for the registration of the brands and grades of specialty fertilizers listed below for the period ending December 31, 20____.
  We agree that the company name and address appearing after “REGISTERED FOR” will be printed on each container associated with the fertilizer and upon approval of this application
  said company assumes full responsibility for compliance with all requirements of the Kentucky Fertilizer Law and Regulations.
                                             Labels MUST be attached for each new brand and grade for which registration is requested

 Check one or more: __New             __Renewal with no changes                   __Renewal with corrections                         __Renewal with deletions

    ___Registered FOR_________________________________               Address__________________________                     City_______________________          State________                Zip____

    ___Registered BY_________________________________                Address__________________________                     City_______________________          State________                Zip____
                        (If different from above)
    ___Annual Insp. Fees___ ___________________________              Address__________________________                     City_______________________          State________                Zip____
                        (If different from above)

  Check one or more:         ___Mixed Blend          ___Mixed Amm-Gran                      ___Mixed Liquid(clear)                   ___Mixed Liquid(susp)               ___Material

  Date ____________           Signature ______________________________            _____________________________                 Phone (      ) ____________ Fax (       ) ____________
                                                                                          (printed name and title)

                       BRAND NAME AND GRADE                          NET WEIGHT OF            GUARANTEED ANALYSIS*                 S/M*       ID/LABEL#**       REGR.          AN.          TOTAL
                          OF FERTILIZER OR                               PKGS.                                                                                  FEES          INSP.
                                                                       (≤10 LBS.)
                                                                                               N          P2O5         K2O
                        FERTILIZER MATERIAL                                                                                                                                   FEES

                                                                                                                                          TOTAL FEES
  *Guarantees other than NPK must be on label and the S/M column checked (√).
  **Place the ID number or your product number from each attached label in this column.

  DO NOT SEND MONEY WITH APPLICATION. You will be billed when labels and application are approved.
  DO NOT WRITE IN THIS SPACE -- FOR USE OF DIVISION OF REGULATORY SERVICES ONLY                                                                        APPLICANT -- Return all copies

  Check Amount _________________              Check Number ____________________                Date of Check ____________________             Date Received ________________________

                                                                                                                                                Total Fees Due (This Report) $_________________

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