Farm Implements Act Program - Application for Distributor Registration

(Please Print or Type)

Name of Applicant: ___________________________________________

Business Name: _____________________________________________

Address of principal place of business serving Ontario:

___________________________________________________________

City, Province: _______________________________________________

County: ____________________________________________________

Postal Code: ________________________________________________

Telephone Number: ___________________________________________

Fax Number: _________________________________________________

E-mail Address: _______________________________________________

Website Address: _____________________________________________

____ Sole Proprietorship

____ Partnership

____ Corporation

Owner/General Manager: ________________________________________

Telephone Number: _____________________________________________

Names and addresses of parts depots in Ontario:

_____________________________________________________________

_____________________________________________________________

_____________________________________________________________

Telephone Number: _____________________________________________

Telephone Number: _____________________________________________

Telephone Number: _____________________________________________

Type of Equipment Sold (Required):

Primary Field Equipment ____

Tractors ____ Tillage ____ No-till ____ Planters ____ Sprayers ____

Manure Handling ____

Harvesting Equipment ____

Combines ____ Balers ____ Mowers _____ Hay Eqpt ____ Forage Eqpt ____

Grain bins ____

Materials Handling Equipment ____

Loaders ____ Augers ____ Elevators ____ Conveyors ____ Wagons ____

Farmstead Equipment ____

Silo Unloaders ___ Feeding Eqpt ___ Ventilation Eqpt ___ Cleaning Eqpt ___

Milking Systems ___

General ____

Snowblowers ____

I, the undersigned, hereby apply for registration as a Farm Implements Distributor in the Province of Ontario and declare that to the best of my knowledge the above information is current and true.

Signature: _____________________________________________________

Name (Print): ___________________________________________________

Position: _______________________________________________________

Date: __________________________________________________________

Please attach:

1. Registration fee of $300 by cheque or money order in Canadian Funds, payable to the Minister of Finance.
2. Names and addresses of dealers in your Ontario dealer network.
3. Names and addresses of implement manufacturers which you represent.
4. A list of all makes (brands) of farm implements offered for sale.

Forward Application To:

Farm Implements Act Program
Ministry of Agriculture, Food and Rural Affairs
Environmental Management Branch
1 Stone Road West, 3SE
Guelph, ON N1G 4Y2

For Department Use Only

Registration Number: _____________________________________________

Date Issued: ____________________________________________________

Fee: ___________________________________________________________

Renewal Date: __________________________________________________

Remarks: ______________________________________________________

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