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TENNESSEE DEPARTMENT OF AGRICULTURE REGULATORY SERVICES WEIGHMASTER LICENSE APPLICATION Name please print Company Phone Number Address City State Zip Code Commodities weighed Are you a U.S. citizen Yes No Are you at least eighteen 18 years of age Yes No I have read and thoroughly understand Tennessee Code Annotated 47-26-1001 et. seq. and in conformity therewith I hereby make the following oath I do solemnly swear or affirm that I will accurately weigh all commodities purchased or offered for sale at the establishment where I am employed which I weigh and I understand that a conviction for incorrect weighing will necessitate the revocation of my license in addition to all other penalties. Signature Scale Operator Date Witness Give at least three 3 character references not related to you A FEE OF 36. 00 MUST ACCOMPANY THIS APPLICATION Please make check payable to Tennessee Department of Agriculture Copy of the Tennessee code Annotated 47-26-1001 is available upon request AG-0193 Ellington Agricultural Ctr Box 40627 Nashville TN 37204 Phone 615 837-5109 Fax 615 837-5015. seq. and in conformity therewith I hereby make the following oath I do solemnly swear or affirm that I will accurately weigh all commodities purchased or offered for sale at the establishment where I am employed which I weigh and I understand that a conviction for incorrect weighing will necessitate the revocation of my license in addition to all other penalties. Signature Scale Operator Date Witness Give at least three 3 character references not related to you A FEE OF 36. Signature Scale Operator Date Witness Give at least three 3 character references not related to you A FEE OF 36. 00 MUST ACCOMPANY THIS APPLICATION Please make check payable to Tennessee Department of Agriculture Copy of the Tennessee code Annotated 47-26-1001 is available upon request AG-0193 Ellington Agricultural Ctr Box 40627 Nashville TN 37204 Phone 615 837-5109 Fax 615 837-5015. seq. and in conformity therewith I hereby make the following oath I do solemnly swear or affirm that I will accurately weigh all commodities purchased or offered for sale at the establishment where I am employed which I weigh and I understand that a conviction for incorrect weighing will necessitate the revocation of my license in addition to all other penalties. Signature Scale Operator Date Witness Give at least three 3 character references not related to you A FEE OF 36. 00 MUST ACCOMPANY THIS APPLICATION Please make check payable to Tennessee Department of Agriculture Copy of the Tennessee code Annotated 47-26-1001 is available upon request AG-0193 Ellington Agricultural Ctr Box 40627 Nashville TN 37204 Phone 615 837-5109 Fax 615 837-5015. .

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