Fertilizer & Soil Conditioner License Registration 30776 MDA Fert App Form 183914 7
User Manual: 30776
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For Offi cial Use Only
Michigan Department of Agriculture & Rural Development
P.O. Box 30776, Lansing, MI 48909 • 517-284-5771
FAX: 517-284-0458 www.michigan.gov/mda-fertilizer
License Year Ending: Dec. 31 Status: New Renewal
If Renewal, Unique ID or License No. of Establishment ____________________________
Business Information
Submitter Name:_____________________________________________________________
Submitter Address:___________________________________________________________
City: ______________________________ State:________ County:____________________
Zip:___________________ Country:_____________________________________________
Phone: (_____)_______________________ Fax: (_____)____________________________
Manufacturer (Label) Name and Address if different from above:________________________
___________________________________________________________________________
Address:____________________________________________________________________
City:________________________________ State:_________ County:___________________ Federal ID or EIN Number
Zip:_________________ Country:________________________________________________ ___________________________
Contact Name:______________________________________________ Phone: (_____)___________ Fax: (_____)______________
Email:_____________________________________ Business Website www.______________________________________________
Total No. of registrations:________ @ $125.00 = $_____________ Total No. of licenses:________ @ $100.00 = $___________
Payment Method: Check/Money Order No. _________________________________________ Amount enclosed:_______________
Please make check/money order payable to the State of Michigan and submit to the address at the top of the page.
Signature:__________________________________________________ Date:___________________
Print name:_____________________________________Print title:________________________________
No Longer Needed
Fertilizer & Soil Conditioner License / Registration Application
In accordance with 1994 Public Act 451, Part 85 as amended.
License Fees (Please indicate all that apply)
Specialty Fertilizer & Soil Conditioner Product Registration (attach additional sheets if needed)
www.michigan.gov/mda-licensing
AOBJ: 0178 Lic • 0264 Reg • 0195 WQ
Remember to attach a product label or invoice with this application
Fertilizer Manufacturer/Distributor & Soil Conditioner Facility License (attach additional sheets if needed)
Facility:__________________________________________ Address:____________________________________________________
City:_____________________________________________ State: ______ County:____________________ Zip:_________________
Application continues
on the back of this form
Product Name Grade
Check product type:
Specialty Fertilizer = S Soil Conditioner = C Benefi cial By-Product = B Please submit 8.5” x 11” copy of the current label for each product N P K
S C B
S C B
S C B
S C B
S C B
PI-106 (Rev 9/17)
Resident Agent (Out-of-State Firms Only)
Out-of-state fi rms must select one of the following:
Michigan Resident Agent
Resident Agent Name:_________________________________________
No Resident Agent (Opt Out)
In lieu of a resident agent, the fi rm will maintain and make fer-
tilizer and soil conditioner records required by law available to
MDARD and pay all costs incurred by MDARD in auditing
the records if they are held at an out-of-state location.
Address:____________________________________________________
Email:_______________________________Phone:(_____)___________
Licenses (one license covers all four uses per facility)
1. Agricultural (farm use) fertilizer manufacturer/distributors
2. Specialty fertilizer custom blenders
3. Soil conditioner custom blenders
4. Benefi cial Use By-Product
For additional questions, please visit our website at www.michigan.gov/mda-fertilizer
Defi nitions
8. Pulp and Paper Mill Material
9. Dewatered Concrete Grinding Slurry from Public
Transportation Agency Road Projects
10. Lime Softening Residuals
11. Soil Washed or Otherwise Removed from Sugar Beets
12. Segregated Flue Gas Desulfurization Material
1. Complete the entire fertilizer application.
2. Submit a label or invoice for each product registration.
3. Check payable to the State of Michigan.
4. Return ALL of the above items to:
Michigan Department of Agriculture & Rural Development
Pesticide and Plant Pest Management Division
P.O. Box 30776 (if payment is due) Use P.O. Box 30017 for all other correspondence
Lansing, MI 48909 Use 525 W. Allegan, Lansing, MI 48933 for overnight delivery
There are two types of registrations and four types of licenses:
Registrations
1. Specialty (non-farm use) fertilizer products
2. Soil conditioner products
Benefi cial Use 3 By Products - The agricultural land application of certain by product materials (see the list below) is now
overseen by MDARD.
• The new license/registration of any benefi cial use 3 materials on the list below must meet additional testing and label-
ing requirements. See www.michigan.gov/mda-fertilizer for an application.
•Existing benefi cial use 3 licenses/registrations (renewals) are not impacted, unless a raw material or generation pro-
cess has changed.
Benefi cial Use 3 Materials
1. Coal Bottom Ash
2. Wood Ash
3. Pulp and Paper Mill Ash
4. Mixed Wood Ash
5. Cement Kiln Dust used as a Flue Gas Scrubbing Reagent
6. Lime Kiln Dust used as a Flue Gas Scrubbing Reagent
7. Foundry Sand from Ferrous or Aluminum Foundries
Grade - Means the percentage guarantee of total nitrogen (N), available phosphate (P2O5), and soluble potash (K2O), of
a fertilizer. Indication of grade does not apply to peat or peat moss or soil conditioners. The grade needs to be in whole
numbers. Specialty fertilizers with a guarantee less than 1% N, P or K (like 0.8%) and straight fertilizer materials may use a
fraction. Custom blends may also use fractional units (tenths of a percent, like 10.5%).
Resident Agent - Someone who is appointed by the licensee to receive any documents, notices, or demands served
upon the licensee. The resident agent must be a Michigan resident, a Michigan corporation, a foreign corporation with a
certifi cate of authority to transact business in Michigan, a Michigan limited liability company or a foreign limited liability
company authorized to transact business in this state.
Soil Conditioner - Any substance that is used or intended for use to improve the physical characteristics of the soil. Soil
conditioner does not include guaranteed plant nutrients, agricultural liming materials, pesticides, unmanipulated ani-
mal or vegetable manures, hormones, bacterial inoculants, and products used in directly infl uencing or controlling plant
growth. A soil conditioner with nutrient value claims is considered a fertilizer.
Specialty Fertilizer - Any fertilizer distributed primarily for non-farm use, such as use in connection with home, gardens,
lawns, shrubbery, fl owers, golf courses, parks, and cemeteries.
Water Quality Protection Fee - A fee of $100 per registered product is assessed in accordance with 1994 Public Act 451,
Part 87, Groundwater and Freshwater Protection, and Part 85, Fertilizers.
Instructions
Types of Registrations and Licenses
