BLOOMFIELD LIVESTOCK MARKET

Source - Age - Process Verification

Producer Name________________________________

Headcount_____________________________________

HomeRaised:Yes__________________NO____________

Weaning date_________________ Unweaned_______

Bone Meal/Meat Meal Free: Yes__________No_________

BQA Certified: Yes____________No__________________

First Calf Born (date)_______________________________

Process Verification

Ear Tag #_____________ Brand__________________

EID________________ Date____________________

Product Used:

certify the above information is correct.

Producer signature_________________________

Date________________________________

BLM Signature_______________________

* Bloomfield Livestock Market has on file mailing address, phone

number, and premise ID number if designated.

Bloomfield Livestock Market PO Box 21 Bloomfield, Ia 52537

641-664-2435