Agriculture

Manitoba Premises Identification Application For Livestock and Poultry

Premises Information

A premises is a parcel of land, on which or on any part of which livestock or poultry are grown, kept, assembled or disposed of at any point during the year. When applying for multiple premises complete an additional form for each premises or contact your local Manitoba Agriculture Office for assistance.

Purpose of Application New Applicant Update

Land Description

Legal Land Description

Parish Lot Parcel

Geo-Referenced Coordinates (decimal degrees)

Name or Description of Premises: (ex: Home Quarter, Summer Pasture, etc.)

Premises Type (select all that apply)

Farm, Stable

Feedlot

Pasture

Community Pasture

Hatchery

Abattoir

Assembly Yard

Auction, Livestock Sale Facility

Rendering Plant

Zoo, Petting Zoo

Exhibition, Fair Ground, Racetrack, Competition Facility

Veterinary Hospital/Clinic/Lab

Insemination Centre

Livestock/Poultry Research Facility

Other

Species Type

Select all species that may be present at any time during the year at this location. For each species indicate the maximum capacity (i.e the maximum number of animals this premises is expected to accommodate). For the other birds and other categories list all applicable species and indicate the maximum capacity for each. Please see the guidelines for a list of the other species to be included.

Civic/911 (i.e. number on sign at driveway – up to six digits):

Contact Information

Emergency Contact Information: (individual responsible for day-to-day operations at premises)

First Name:

Middle Initial:

Last Name:

Business/Farm Name:

Mailing Address:

Town/City:

Postal Code:

Home Phone Number:

Business Phone Number:

Cell Phone Number:

Fax Number:

E-Mail:

Relationship of emergency contact to premises:

Is the Land Owner Information different than the Emergency Contact? Yes No

Land Owner Information

First Name:

Middle Initial:

Last Name:

Business/Farm Name:

Mailing Address:

Town/City:

Postal Code:

Home Phone Number:

Business Phone Number:

Cell Phone Number:

Fax Number:

E-Mail:

Notice of Collection of Personal Information

The personal information on this form is being collected for the Premises Identification Program of Manitoba Agriculture under the authority of section 3(1) of the Animal Premises Identification Regulation 104/2010 under The Animal Diseases Act, and will be used for one or more of the following purposes, described in section 2(2) of the Regulation:

(a) detecting, preventing, controlling, managing and eliminating disease;
(b) analyzing the geographical distribution of disease and the epidemiology of disease outbreaks;
(c) conducting assessments and models to prevent disease risk;
(d) tracking the movement of animals from premises to premises;
(e) protecting animal health and human health;
(f) emergency planning;
(g) eliminating disease barriers to market access;
(h) checking the accuracy of information collected or provided under this regulation.

And may be disclosed to the following persons or entities, under section 6(2) of the Regulation:

(a) a department, branch, office or agency of the Government of Manitoba;
(b) the Government of Canada or a municipal, provincial or foreign government, or an agency of such a government, or a person or body whose duties and interests include

(i) protecting the public health
(ii) monitoring or reporting on the safety of agricultural inputs, food, livestock or livestock products, or
(iii) monitoring or reporting on the biological, chemical and physical integrity of agricultural inputs, food, livestock or livestock products;

The personal information is protected by the privacy provisions of The Freedom of Information and Protection of Privacy Act. Other than in circumstances referenced in this notice the personal information will only be disclosed where authorized by law. If you have any questions concerning the collection, use or disclosure of the personal information, please contact the FIPPA Access and Privacy Coordinator, Manitoba Agriculture at 204-945-4823.

Additional Information

For more information, contact your local Manitoba Agriculture Office, call Manitoba Government Inquiry at
1-866-626-4862 to help locate your nearest office or email traceability@gov.mb.ca.