LP-110 Work Schedule Request

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

WORK SCHEDULE REQUEST

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.
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.

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

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

Grading of Shell Eggs (7 CFR Part 56)

Quality Systems Verification Programs (7 CFR Part 62)

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

The provisions of the above selected Regulations shall be applicable to this application and the signers thereof. The days and number of hours shown below will be established as the
normal work schedule for this plant(s). The firm may terminate the application at their discretion, effective at close of business on any Saturday, by giving written notice to the
Business Operations Branch at least 30 days prior to such Saturday. The following hours of service are requested for this agreement.

Applicant Name:

FSIS/Plant Number:

Location of Service Address:

Date:

Sunday

Title of Applicant Representative:

Wednesday

Thursday

Sunday

Title of Applicant Representative:

Monday

Tuesday

Wednesday

Signature of Applicant Representative:

Applicant Name:
Sunday

Title of Applicant Representative:

Monday

Tuesday

Signature of Applicant Representative:

Saturday

Total Hours

Miles:
Thursday

Friday

Saturday

Total Hours

Email Address:

FSIS/Plant Number:

Location of Service Address:

Friday

Email Address:

FSIS/Plant Number:

Location of Service Address:

Date:

Tuesday

Signature of Applicant Representative:

Applicant Name:

Date:

Monday

Miles:

Wednesday

Miles:
Thursday

Friday

Saturday

Total Hours

Email Address:

SPECIAL PROVISIONS:

FOR OFFICIAL USE ONLY
Effective Date of Agreement:
(Sunday only)

Approved By:
(Signature)

LP-110 (XX/20XX) Supersedes LPS-110

Date Signed:

EXP. DATE: XX/XX/XXXX