LPS-109 Application for Service

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

U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
Livestock and Poultry Program
Quality Assessment Division

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, employer, and lender.

APPLICATION FOR
SERVICE
Submit Completed Form to:
(Choose one option)

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.

USDA, MRP, AMS, L&P, QAD
Business Operations Branch
10809 Executive Center Drive, Suite 318
Little Rock, AR 72211-6022

Email:
Telephone:
Fax:

QAD.BusinessOps@usda.gov
501-312-2962
1-844-345-3575

New Application
Change of Address
Revision

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
Pork
Chicken
Rabbit
Geese
**Shell Egg

Lamb
Veal/Calf
Turkey
Duck

TYPE
Scheduled
Unscheduled

_________________________________

GRADING SERVICES
CN Labeling
Grading
Processing
Product Certification
Product Examination
Temperature Verification
Test Weight

AUDITING SERVICES
Commodity Procurement
Export Verification (e.g. NHTC, PEEPEV, PFEU)
National Organic Program
Process Verified Program
Quality System Assessment Program
Verified Operations Registry (e.g. Grass Fed, Tenderness, USHSLA)
___________________________________________________________

______________________________

REGULATIONS APPLICABLE TO REQUESTED SERVICE(S):
Meats, Prepared Meats, and Meat Products (Grading, Certification, and Standards) (7 CFR Part 54)
Quality Systems Verification Programs (7 CFR Part 62)

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

Grading of Poultry Products and Rabbit Products (7 CFR Part 70)
Grading of Shell Eggs (7 CFR Part 56)

APPLICANT INFORMATION

Tax ID Number:

Small Business:

Yes

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).

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

PLANT NUMBER:

No

FSIS or NFI Est. NUMBER:

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

E-MAIL ADDRESS:
PHONE NUMBER:

PHONE NUMBER:

**SHELL EGG CERTIFICATION: I agree to comply with the terms and conditions of the regulations as applicable to the service(s) requested (including but not
limited to such procedures 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 (We) agree:
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 comply with Public Law 84-272 (7 U.S.C. 1622(h)) a copy of which has been received, read, and understood.
3. To notify the Business Operations Branch immediately when a change occurs in the legal status of the applicant, see contact information above.
4. To notify the Business Operations Branch, in advance and in writing, of cancellation of this application, see contact information above.
PRINT NAME & TITLE OF APPLICANT:
SIGNATURE OF APPLICANT:

DATE:

APPROVED BY:
(Signature)

DATE:

FOR OFFICIAL USE ONLY

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.
EXP. DATE: XX/XX/XXXX
LP-109 (XX/20XX) Supersedes LPS-109