Please complete all sections that apply.
If you have any question, contact Joe Collins

Business name:
Address:
City:	State:
Zip:
County:
Phone:	FAX:
E-mail:
Owner/Manager:

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Mailing Address (if different from above)

Business name:
Address:
City:	State:
Zip:
County:
Phone:	FAX:
E-mail:
Owner/Manager:

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Nursery Location (Map and/or directions):

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Type of Business: Class A Dealer - $40.00/location; Garden center, landscaper or other business that does not grow or overwinter nursery stock.

Method of Production
Field, Number of Acres in production: (enter total acres)
Greenhouse: Acres: or Square Feet: (enter total acres or square feet)
Containerized production
Propagation (check all that apply):
      Bare root, Container, Tissue culture, Seed, Other:
Other:

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List sources from which your nursery stock will be obtained: (name, address and phone)
i.e. John Doe Nursery, 123 Any Street, Somewhere, State 12345, (xxx) xxx-xxxx

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Method of Marketing (Check all that apply)
Wholesale: Do you currently ship plant material out of state? Yes No
Retail (Garden center, mass merchandiser, etc.)
Landscaping/Landscape contracting
Government Agency
Other: Specify

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Type of Nursery Stock
Conifer trees
Conifer shrubs
Shade & ornamental trees
Flowering & ornamental woody shrubs or vines
Ground covers
Herbaceous perennials
Sod
Fruit trees
Nut trees
Bush & vine fruit
Roses
Other:

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Applicant Name:

Signature:_________________________________________________

Date:

Please make checks payable to: Kentucky Agricultural Experiment Station (Ky Ag Exp Station).
Mail payment to:
Office of State Entomologist
University of Kentucky
S-225 Ag. Sci. Center - N
Lexington, Kentucky 40546-0091
Attn: Joe Collins