Form D - Farm Implementation Act

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Application for Licence as a Distributor
Form D - Farm Implement Act
Business Name
Mailing Address
City/Town
Province
Business Telephone Number (include area code)
Postal Code
Fax Number (include area code)
If address is outside of Alberta, please state Registered Office in the Province of Alberta
Names of all principals of firm or partnership
Contact Personnel:
General Manager
Telephone Number (include area code)
Warranty Manager
Telephone Number (include area code)
Service Manager
Telephone Number (include area code)
Parts Manager
Telephone Number (include area code)
Controller
Telephone Number (include area code)
List Alberta Dealers
Name and Address
Telephone Number (include area code)
Attach sheet if space is insufficient
List farm implements distributed to Alberta Dealers
Brandline
Manufacturer
Type of Equipment
Attach sheet if space is insufficient
This application is for
Licence Renewal
or
Initial Licence Application
I, the undersigned, hereby apply for a licence as a Farm Implement Distributer in Alberta and declare that the above
information is current and true to the best of my knowledge.
Signature
Date
**NOTE** Licence Fee and Levy will apply.
Forward Application To:
Farm Implement Act Administration
Alberta Agriculture and Rural Development
Room 305, J.G. O'Donoghue Building
7000 113 Street, Edmonton AB T6H 5T6
Telephone: 310-FARM (3276) or 403-742-7901
Fax: (780) 427-3913
This information is being collected in order to administer the “Farm Implement Act
Administration” Program. The information is being collected in compliance with
section 33 (c) of the Alberta Freedom of Information & Protection of Privacy Act.
The information is used only for the purpose it was selected or for a consistent
purpose. If you have any questions, regarding the information collected here or its
use, please contact the Farmers' Advocate Office at 310-3276 or 403-742-7901
outside of Alberta.
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ADMINARD0005 (2012/03)
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