Section 16B. Applications for the registration of dairy farms under section sixteen C shall be made upon blanks furnished by the commissioner and shall contain, in addition to such other information as may be required by the commissioner, a statement of the name, place of residence and business address of the applicant, the amount of milk produced on his dairy farm during the calendar month last preceding the date of application, the number of dairy cows more than two years of age and the number of heifers less than two years of age kept on said dairy farm during said month, the names and business addresses of dealers, distributors and wholesale purchasers who receive milk from said dairy farm, together with a statement of the estimated amount of milk to be supplied each dealer, distributor and wholesale purchaser during such period as may be designated by the commissioner. Every statement shall be verified by oath or written declaration that it is made under the penalties of perjury.