DA-162 Equipment Review Request

Reproduce Locally. Include form number and edition date on all reproductions Form Approved OMB No. 0581-0126

U. S. DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE DAIRY PROGRAMS EQUIPMENT REVIEW REQUEST
Applicant (Name and Address)	Party Responsible for Payment if other than Applicant (Name and Address) Confirmation Required (Letter or Fax) Received 				Equipment Located at (Name and Address)
Website
Tax Identification No. (TIN)	Tax Identification No. (TIN)				Inspection Date(s) Requested:
Contact	Contact				Contact
Telephone	Telephone				Telephone
Fax	Fax				Fax
Type of Equipment:		Review for:		Dairy Livestock and Poultry 3-A Third Party Verification Appeal
Signature of Applicant	Date					Email
 Domestic Inspection: A minimum of seven (7) working days notification is required to insure specialists have ample time to make arrangements for the trip. If specialists are unavailable, the next available date acceptable to all parties will be assigned.
 Foreign Inspection: A minimum of thirty (30) working days advance notice is required for any foreign travel. The 30 days will start from the date this request form Is received by the Dairy Grading Branch. If specialists are unavailable, the next available date acceptable to all parties will be assigned. Hotel accommodations (USDA Dairy must pay): Best mode of transportation from airport (train, taxi, company pickup…): Does the Hotel accept Visa credit cards:  Yes  No
Mail or Fax this form for All Reviews to: USDA/AMS/DAIRY PROGRAMS Dairy Grading Branch Design Review Section Room 2746 – South Building 1400 Independence Ave. SW STOP 0230 Tel: 202 720-3171 Washington, DC 20250-0230 Fax: 202 720-2643
The Following statements are made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a) and the Paperwork Reduction Act of 1995. The authority for requesting this information to be supplied on this form is the Agricultural Marketing Agreement Act of 1937, Secs. 1-19, 48 Stat. 31, as amended, (7 U.S.C. 601-674). Furnishing the requested information is necessary for the administration of the marketing order program. According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0581-0126. The time required to complete this collection of information is estimated to average 3 minutes per person including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance program. (Not all prohibited bases apply to all programs). Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at 202-720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.
FOR OFFICIAL USE ONLY
Date Received: __________ Date Assigned: __________			Specialist Assigned: __________ Project Number (s): __________

DA-162 (01-09) Destroy previous edition dated 10-03

DA-162 Form Completion Instructions

1. Applicant

a. Enter Your Company name as you want it to be listed.

b. Enter your mailing address, a second line is provided for longer street addresses

c. Enter your City name

d. Enter your State two letter code, or Country name if other than the USA.

e. Enter your Zip or Postal code

f. Enter your company E-mail.

g. Enter your company website as you want it listed.

h. If you are a new applicant, enter you Tax I.D. Number.

i. Enter the contact person’s name.

j. Enter your company’s telephone number. If you wish enter the contact person’s extension number.

k. Enter your Company’s fax number

12. Sign the document. This is required to guarantee payment for services rendered.

2. Party Responsible for Payment if other than Applicant

a. Confirmation Required – USDA will complete

b. Received - USDA will complete

c. Enter Your Company name as you want it to be listed.

d. Enter your mailing address, a second line is provided for longer street addresses

e. Enter your City name

f. Enter your State two letter code, or Country name if other than the USA.

g. Enter your Zip or Postal code

h. Enter your company E-mail address.

i. If you are a new applicant, enter you Tax I.D. Number.

j. Enter the contact person’s name.

k. Enter your company’s telephone number. If you wish enter the contact person’s extension number.

l. Enter your Company’s fax number

3. Equipment Location –Complete this section only if equipment is at a location other than listed in “Applicant” or “Party Responsible for Payment”.

a. Enter Your Company name as you want it to be listed.

b. Enter your mailing address, a second line is provided for longer street addresses

c. Enter your City name

d. Enter your State two letter code, or Country name if other than the USA.

e. Enter your Zip or Postal code

f. Enter your company E-mail address.

g. Enter the contact person’s name.

h Enter your company’s telephone number. If you wish enter the contact person’s extension number.

i. Enter your Company’s fax number

4. Type of Equipment: Select Dairy, Meat and Poultry, or 3-A Third Party Verification

5. Domestic Inspection check box: Check if inspection is within the United States or territories

5. Foreign Inspection check box: Check if inspection is to be outside of the United States or territories.

   1. Hotel Accommodations – Provide Hotel name and Telephone number, including city and country codes.

   2. Best mode of transportation from the airport – Please advise of the best way to get from the airport to the hotel or inspection site.