LPS-109 Application for Service (paper version)

REPRODUCE LOCALLY. Include form number and edition date on all reproductions.
U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
Livestock, Poultry, and Seed Program
Quality Assessment Division

APPLICATION FOR
SERVICE

OMB APPROVED: NO. 0581-0128

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 0581-0128. The time
required to complete this information collection is estimated to average 15 minutes per response, including the 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, 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 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 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.

Submit Completed Form to: USDA, MRP, AMS, LPS, QAD
Email:
QAD.BusinessOps@ams.usda.gov
New Application
Business Operations Branch
Telephone: 501-312-2962
Change of Address
10809 Executive Center Drive, Suite 318
Fax:
501-312-2968
Revision
Little Rock, AR 72211-6022
In accordance with the applicable provisions of the regulation issued by the Agricultural Marketing Service, U.S. Department of Agriculture, application is hereby made for the
furnishing of the service(s) checked below to be performed at the plant specified:

COMMODITY
Beef

Commitment

Lamb

Non-Commitment

Further Processing

AUDIT SERVICES
Export Verification
National Organic Program

Pork

Resident

Processing

Non-Hormone Treated Cattle

Poultry

Non-Resident
Temporary

Product Certification
Temperature Verification

**Shell Egg

Fee

Test Weight

Veal/Calf

_____________

TYPE

Rabbit

___________________

SERVICES
Grading

Pork for the European Union
Process Verified Program
Seed Accreditation Programs (ASL,AFIP,ASSP)

Product Examination
___________________________

Quality System Assessment Program
USDA ISO Guide 65 Program
______________________________

REGULATIONS APPLICABLE TO REQUESTED SERVICE(S):
Grading of Shell Eggs (7 CFR Part 56)
Meats, Prepared Meats, and Meat Products (Grading, Certification, and Standards) (7 CFR Part 54)
Grading of Poultry Products and Rabbit Products
Livestock, Meat, and other Agricultural Commodities (Quality Systems Verification Programs)
(7 CFR Part 70)
(7 CFR Part 62)

APPLICANT INFORMATION
NAME OF APPLICANT (As shown on your income tax return)

Tax ID Number:
This is the Corporate Tax ID number unless the entity submitting the application is an individual, then the Social Security Number is Required. (Required by IRS).
PLANT NUMBER:
FSIS or NFI Est. NUMBER:

BILLING ADDRESS OF APPLICANT (Street and No., City, State, and ZIP Code)

NAME & PHYSICAL ADDRESS WHERE SERVICE(S) WILL BE PERFORMED
(Street and No., city, State, and ZIP Code)

E-MAIL ADDRESS:

**CERTIFICATION: I agree to comply with the terms and conditions of the regulations applicable to the service(s) requested (including but not limited
to such instructions governing such service as may be issued, from time to time, by the Agricultural Marketing Service). I also agree to notify the
Agricultural Marketing Service of any contaminated or adulterated (chemical, physical, or biological agents) shell eggs in the processing plant and to
assure identification and segregation of such product. This notification includes shell eggs that have tested positive for Salmonella Enteritidis (SE) or shell
eggs from houses determined positive for the presence of SE, or any shell eggs that have been recalled or subject to any recall. I also agree to provide
the AMS grader detailed information pertaining to the method of identification and segregation required of any shell eggs that have been determined to be
contaminated, or adulterated, including eggs from an identified layer flock that tests positive for the presence of SE. I hereby acknowledge receipt of a
copy of Public Law 84-272 (7 U.S.C. 1622(h)) and the regulations under which this application is made.
I (We) agree to:
1. To comply with all applicable provisions of the Code of Federal Regulations (CFR) identified under “Regulations Applicable to Service(s) Requested,”
a copy of which has been received and read.
2. To notify the Business Operations Branch immediately when a change occurs in the legal status of the applicant, see contact information above.
3. To notify the Business Operations Branch, in advance and in writing, of cancellation of this application, see contact information above.
4. Any service requested via this application may be denied or withdrawn at any time as provided in the applicable CFR, program policies & procedures.
PRINT NAME & TITLE OF APPLICANT:
DATE:

SIGNATURE OF APPLICANT:

FOR OFFICIAL USE ONLY
DATE:

APPROVED BY (Signature)

TITLE

*No member of or delegate to Congress, or Resident Commissioner, shall be admitted to any benefit that may arise from this service unless derived through
service rendered a corporation for its general benefit.
LPS- 109 (02/2015)