Application for a Non-Shopkeeper-Distributor Licence

Fields marked with an asterisk (*) are mandatory.

Type of Application(required)

New

Renewal

Licence Number(required)

(Format must be 6-digit)

Section 1. Business Information

Legal Business Name (the licence will be issued under the Legal Business Name)(required)

Business Operating Name (if different than Legal Business Name)

Physical Address

Postal Code(required)

(Format must be A#A #A#)

(if necessary, continue to select the Postal Code Lookup button until your correct street name is shown or complete the address fields with the correct information)

Unit Number

Street Number(required)

Street Name(required)

PO Box

City, Town or Village(required)

Province(required)

Office or Mailing Address

Check if same as Physical Address

Postal Code(required)

(Format must be A#A #A#)

Unit Number

Street Number(required)

Street Name(required)

PO Box

City, Town or Village(required)

Province(required)

Section 2. Applicant Information

Last Name(required)

First Name(required)

Position Title(required)

Telephone Number(required)

(Format must be 10 digits)

Extension

Email Address(required)

(Example: name@example.com)

Confirm Email(required)

(Example: name@example.com)

Canada Revenue Agency (CRA) Business Number

Do you have a CRA Business Number?(required)

Yes

No

CRA Business Number(required)

(Format must be 9-digit)

Indicate your reason for exemption(required)

CRA Business Number Exemption (My business has no employees and/or it earns under $30,000 in gross revenue. Therefore, I confirm I am not legally required to obtain a CRA business number under the Income Tax Act (Canada).)

Religious Exemption (I confirm although I am legally required to obtain a CRA business number under the Income Tax Act (Canada), I have not obtained one because I have a sincerely held belief that doing so would be or is contrary to my religion, belief or conscience.)

Section 3. Depot Information

Do you have one or more depot locations(required)

Depot locations are locations under your care and control at which fluid milk products are stored or transferred as part of your business as a non-shopkeeper-distributor.

Yes

No

Depot Location 1

Postal Code(required)

(Format must be A#A #A#)

Unit Number

Street Number(required)

Street Name(required)

City, Town or Village(required)

Province(required)

Depot Location Type(required)

Building with refrigeration equipment

Cross-dock (location where fluid milk products are transferred from one truck to another)

Immobilized refrigerated trailer

Refrigerated warehouse

Section 4. Supplier Information

Please provide the business name and Non-Shopkeeper Distributor (NSD) licence number for your fluid milk suppliers. For a list of licenced NSDs, go to Guidelines for non-shopkeeper distributors of fluid milk products | ontario.ca.

Supplier 1

Supplier Business Name(required)

Supplier NSD Licence Number(required)

(Format must be 6-digit)

Do you pick up milk at your supplier's depot location(s)?(required)

Yes

No

Do your suppliers deliver milk to your depot location(s)?(required)

Yes

No

Section 5. Delivery Information

Are there non-dairy products that will be distributed on the vehicle(s) (e.g. produce, meat, eggs, chemicals etc.)?(required)

Yes

No

Please select the appropriate checkbox(es) below:(required)

Please specify(required)

What type of segregation exists between the fluid milk products and non-dairy products?(required)

adequate space between non-compatible products

physical barrier

wrapped skids/pallets

Section 6. Attestations

I hereby apply for a Non-Shopkeeper-Distributor licence under the Milk Act and the regulations and in support of this application declare the information on this application form and attachments to be true.

By signing this form, I understand and agree the Government of Ontario may verify any information provided herein to ensure it is correct and accurate. I further understand and agree the Government of Ontario may use any information provided herein for other purposes, such as auditing, verifying other information I have provided to the Government of Ontario and the collection of any debts I may owe to the Government of Ontario.

Any information and all supporting documents required for this application are collected for and will be used to verify eligibility for a licence pursuant to Reg. 761 - Milk and Milk Products (Milk Act) and may be used for general enforcement and administration purposes under the Milk Act.

The information supplied on this form may be subject to disclosure under the Freedom of Information and Protection of Privacy Act.

I certify that the information submitted in this application is true and correct to the best of my knowledge.(required)

Name of Applicant (First and Last Name) (Same as section 2 on this application)

Date (yyyy/mm/dd)(required)

As part of providing accessible service, you can also contact the Agricultural Information Contact Centre (AICC) at 1-877-424-1300 or by e-mail at ag.info.omafra@ontario.ca if you require this information in alternate formats.

Summary

Note: To make changes to the information below, please click the “Back” button (at the top of this page) to access previous pages or “Edit Section” to make corrections.

Application for a Non-Shopkeeper-Distributor Licence

Section 1. Business Information

Physical Address

Office or Mailing Address

Section 2. Applicant Information

Canada Revenue Agency (CRA) Business Number

Section 3. Depot Information

Depot Location 1

Section 4. Supplier Information

Supplier 1

Section 5. Delivery Information

Section 6. Attestations

Summary

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