LP-109 Application for Service

OMB APPROVED: NO. 0581-0128
REPRODUCE LOCALLY. Include form number and edition date on all reproductions.

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

U.S. DEPARTMENT OF AGRICULTURE

collec-tion 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.

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

Email Completed Form to: USDA, MRP, AMS, L&P, QAD
Business Operations Branch

Email: QAD.BusinessOps@usda.gov
Telephone:
501-312-2962

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:

GRADING SERVICES
TYPE
Scheduled
Unscheduled
Temporary

COMMODITY
Beef
Chicken
Duck
Geese

Lamb
**Shell Egg
Pork
Turkey
Rabbit
Veal/Calf
Other: __________________

SERVICES
CN Labeling
Product Examination
Grading
Remote Grading
Processing
Temperature Verification
Product Certification
Test Weight
Other: ____________________________

PLANT NUMBER
I need an official plant number.

New: ___________________
Current: _________________
FSIS Est. #: ______________
NFI Est. #: _______________

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

REGULATIONS APPLICABLE TO REQUESTED SERVICE(S)
Meats, Prepared Meats, and Meat Products (Grading, Certification, and Standards)(7 CFR part 54)
Grading of Poultry Products and Rabbit Products (7 CFR part 70)
Grading of Shell Eggs (7 CFR part 56)
Audit Verification and Accreditation Programs (7 CFR part 62)

APPLICANT INFORMATION
NAME OF APPLICANT:

(As shown on your income tax return)
Doing Business As (If applicable):
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)

NAME & PHYSICAL ADDRESS WHERE SERVICE(S)
WILL BE PROVIDED: (Street and No., City, State, and Zip Code)

E-MAIL ADDRESS:

COUNTY:

PHONE NUMBER:

PHONE NUMBER:
APPLICANT ACCOUNTS PAYABLE INFORMATION

ACCOUNTS PAYABLE DEPARTMENT MAILING ADDRESS:
(Street and No., City, State, and Zip Code + 4)

CONTACT NAME:
E-MAIL ADDRESS:
PHONE NUMBER:
FAX NUMBER:

LP-109 (XX/20XX)

*****CONTINUE TO PAGE 2*****

No

**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.
REMARKS:

PRINT NAME OF APPLICANT:
PRINT TITLE OF APPLICANT:
SIGNATURE OF APPLICANT:

DATE:

FOR OFFICIAL USE ONLY
APPROVED BY SIGNATURE:

DATE:

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.

ACCOUNT NUMBER:
REQUEST NUMBER:

LP-109 (XX/20XX) REVERSE

EXP. DATE: XX/XX/20XX