LPS-82 LAMB--Application for Certification of Organization

REPRODUCE LOCALLY. Include form number and edition date on all reproductions.

FORM APPROVED - OMB NO. 0581-0093

Note: 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 0581-0093. The time
required to complete this information collection is estimated to average 30 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.

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

APPLICATION FOR CERTIFICATION
OF ORGANIZATION

NOTE: Information is collected in order to determine eligibility of organizations to nominate lamb producers, Please mark an "X" in appropriate block for which
seedstock producers, feeders and first handlers to serve as members of the Lamb Promotion, Research, and organization or association you are applying for
Information Board (Board). Application is voluntary and information is held confidential.
certification: (Mark only one box):
Organizations must apply for certification by the Secretary to be eligible to participate in the making of
Producer
nominations of lamb producers, seed stock producers, feeders and first handlers to serve as members of the Board
as provided in the Lamb Promotion, Research, and Information Order (Lamb Order). Information submitted in
Seedstock Producer
response to all items must be complete. Please type or print clearly. Send original only to:
Research and Promotion Division
Feeder
Livestock, Poultry, and Seed Program, AMS, USDA
First Handler
Street
State, City Zip

2. TELEPHONE

1. NAME AND ADDRESS OF ORGANIZATION (Include street address or P.O. Box No., City, State, ZIP)

3. TYPE OF ORGANIZATION
(State, Regional, National)

4. TOTAL ACTIVE MEMBERSHIP
(Most RECENT FULL calendar year)

In

Number

5. NUMBER OF ACTIVE MEMBERS ENGAGED 6. TOTAL ESTIMATED "PRODUCER" SALES OF
FIRST HANDLER PURCHASE OF LAMB BY
LAMB PRODUCTION FEEDING OR
SLAUGHTER,
ACTIVE MEMBERS
(Most RECENT FULL calendar year)
(Most RECENT FULL calendar year)

In

As of Jan. 1,

Number

Number

7. AS EVIDENCE OF THE STABILITY AND PERMANENCY OF THE ORGANIZATION, GIVE:

A. Number of years in existence

B. Number of active members during each of the last four calendar years:
CALENDAR YEAR
NUMBER

C. Other evidence (Explain):

8. LIST THE SOURCE(S) FROM WHICH THE ORGANIZATION'S OPERATING FUNDS ARE DERIVED:
9. DESCRIBE THE FUNCTIONS OF THE ORGANIZATION:

10. DESCRIBE THE ORGANIZATION'S ABILITY AND WILLINGNESS TO FURTHER THE PURPOSE AND OBJECTIVES OF THE LAMB ORDER:

11. DESCRIBE THE GEOGRAPHIC TERRITORY COVERED BY THE ACTIVE MEMBERSHIP OF THE ORGANIZATION:

12. DESCRIBE THE NATURE OR MAKE-UP OF YOUR ACTIVE MEMBERSHIP. INDICATE THE PROPORTION OF THE TOTAL NUMBER OF PRODUCERS, SEEDSTOCK
PRODUCER, FEEDERS, AND FIRST HANDLERS IN THE STATE OR GEOGRAPHIC AREA SERVED WHICH ARE ACTIVE MEMBERS OF THE ORGANIZATION:

CERTIFICATION STATEMENT
I hereby certify that: (1) an interest of this organization is in the production or marketing of lamb or lamb products and (2) the information provided in response to the
above items is true, complete, and correct to the best of my knowledge. The Secretary of Agriculture may examine our books, documents, papers, records, files, and
facilities to verify any of the information submitted and may procure such other information as may be required to determine this organization's eligibility for
certification.
NAME AND TITLE OF PERSON COMPLETING THIS APPLICATION (Print or type)

LPS-82 (Rev. 04/17) (Destroy previous edition.)

SIGNATURE

DATE

See reverse for burden/non-discrimination statement

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its
Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on
race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status,
family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in
any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by
program or incident.
Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American
Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA
through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.
To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at
http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of
the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to
USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW.,
Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. USDA is an equal opportunity provider,
employer, and lender.