Form DA-155 Application to use Official Identification/Labels

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 APPLICATION TO USE OFFICIAL IDENTIFICATION OR GRADE LABELS
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 control number for this information is 0581-0126. The time required to complete this information collection is estimated to average 1 minute per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection 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, parental 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 for all programs.) Persons with disabilities who require alternative means for communications 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 to 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. USDA official identification or grade labels may not be used unless a completed application has been received and approved.
Application is hereby made, in accordance with the provisions of the appropriate sections of the Regulations Governing the Inspection and Grading of Manufactured or Processed Dairy Products (7 CFR, Ch. I, Part 58, Subpart A), or the Regulations Governing the Certification of Sanitary Design and Fabrication of Equipment Used in the Slaughter, Processing, and Packaging of Livestock and Poultry Products (7 CFR, Ch. I, Part 54, Subpart C), for the privilege of using official identification or grade labels on product packaging materials, equipment, utensils, or descriptive or promotional materials. In requesting this privilege, the applicant (listed below) agrees to conform to the aforesaid regulations and such instructions as may be issued by the Administrator, Agricultural Marketing Service covering inspection, grading and evaluation of products, packaging materials, equipment, utensils, or descriptive or promotional materials. The applicant further agrees to furnish copies of the official identification or grade labels at no cost to the Government. The applicant further agrees not to offer for sale or publicly display any inspected, graded or evaluated product in packaging materials, equipment, utensils, descriptive or promotional materials bearing official identification or grade label under a trade name other than that of the applicant unless such trade name is submitted, together with the proper address, to the Administrator at the time approval is requested of the official identification or grade label to be used. In the event the privilege to use official identification or grade labels on product packaging materials, equipment, utensils, or descriptive or promotional materials is withdrawn in accordance with the appropriate provisions of the aforesaid regulations, the applicant agrees to promptly place under the jurisdiction and control of a USDA licensed grader or design review specialist all packaging materials, descriptive or promotional materials, and other supplies bearing printed reference to the inspected, graded or evaluated character of the products, equipment, or utensils for such subsequent use by the applicant as may be approved by the Administrator.
Name, Address and Plant No. (if applicable) of Applicant:	Send this form and attached materials to: Grade Label Coordinator USDA/AMS/Dairy Programs Dairy Grading Branch Room 2746-S MS 0230 1400 Independence Ave. SW Washington, DC 20250-0230 Tel: 202-720-3171 Fax: 202-720-2643
Name and Title of Applicant Representative (Print or Type):
Applicant Representative Signature:		Date:
Name and Title of Applicant Representative (Print or Type):	Date:	Control Number:

Form DA-155 (01-09) Destroy all previous editions.