STATE OF DELAWARE

MATTRESS, PILLOW AND BEDDING PROGRAM
TITLE 16 DELAWARE CODE CHAPTER 21

APPLICATION FOR INITIAL PERMIT AND PERMIT RENEWAL
TO SELL, LEASE AND/OR SHIP SANITIZED USED BEDDING PRODUCTS INTO DELAWARE 

Answer all questions and return to:	DPH HSP OFP
(Print legibly)			            417 FEDERAL ST
DOVER, DE  19901-3635	   Ph: 302-744-4546   Fax: 302-739-3839

1.   Legal name of business to appear on permit:

____________________________________________________________________________________________
 
      Address to mail permit (include business name if different from above):

____________________________________________________________________________________________

____________________________________________________________________________________________

2.  List all bedding products sanitized_____________________________________________________

____________________________________________________________________________________________

3.   Address of business where sanitization takes place_____________________________________

____________________________________________________________________________________________

4.   Method of Sanitization:________________________________________________________________


-  	Attach one (1) Law Label bedding tag with Uniform Registry Number (URN) and Sanitization Permit Number 
	Uniform Registry Number_________________   Sanitization Permit Number____________________
	Note:  Sanitization Permit Number and Delaware Bedding Permit Number are two separate numbers.
	The latter is the number of the permit for which you are applying. The former is on the law label. 

      	No permit will be issued without an original law label attached to application.
	- Each different Uniform Registry Number requires a separate permit application and $50 fee.
	- Make additional copies of this application as needed.

	- Enclose check or money order in amount of $50.00 US payable to STATE OF DELAWARE

Check No:

Contact Information: (Please print legibly and sign in ink)

Name of person to whom permit will be sent:_________________________________________________	

Phone No & Extension__________________________________ Fax No.	____________________________
Note:  This office cannot place telephone calls or send faxes outside U.S.

E-MAIL Address:	____________________________________________________________________________	

Date: __________________________    Signature of Applicant:

Applicant - Do not write below the dotted line

Date Approved: _____________Date Permit Issued:_____________  Bedding Permit Number___________________

Signature of Official: _______________________________________  PAID STAMP:

Revised: 9/2008								Doc. # 35-05-20/08/10/27