Reproduce Locally. Include form number and edition date on all reproductions. Form Approved OMB No. 0581-0126 

U. S. DEPARTMENT OF AGRICULTURE 

AGRICULTURAL MARKETING SERVICE 

DAIRY PROGRAMS 

APPLICATION TO USE OFFICIAL IDENTIFICATION OR GRADE LABELS 

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 control number for this information is 0581-0126. The time required to complete this information collection 

is estimated to average 1 minute per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 

needed, and completing and reviewing the collection information. 

 The U.S. Department of Agriculture (USDA) prohibits discrimination in all of its programs and activities on the basis of race, color, national origin, age, disability, 

 and where applicable, sex (including gender identity and expression), marital status, familial status, parental status, religion, sexual orientation, political beliefs, genetic 

 information, 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).

 USDA official identification or grade labels may not be used unless a completed application has been received and approved.

 Application is hereby made, in accordance with the provisions of the appropriate sections of the Regulations 

 Governing the Inspection and Grading of Manufactured or Processed Dairy Products (7 CFR, Ch. I, Part 58, 

 Subpart A), or the Regulations Governing the Certification of Sanitary Design and Fabrication of Equipment Used in 

 the Slaughter, Processing, and Packaging of Livestock and Poultry Products (7 CFR, Ch. I, Part 54, Subpart C), for 

 the privilege of using official identification or grade labels on product packaging materials, equipment, utensils, or 

 descriptive or promotional materials. 

 In requesting this privilege, the applicant (listed below) agrees to conform to the aforesaid regulations and such 

 instructions as may be issued by the Administrator, Agricultural Marketing Service covering inspection, grading and 

 evaluation of products, packaging materials, equipment, utensils, or descriptive or promotional materials. The 

 applicant further agrees to furnish copies of the official identification or grade labels at no cost to the Government. 

 The applicant further agrees not to offer for sale or publicly display any inspected, graded or evaluated product in 

 packaging materials, equipment, utensils, descriptive or promotional materials bearing official identification or grade 

 label under a trade name other than that of the applicant unless such trade name is submitted, together with the 

 proper address, to the Administrator at the time approval is requested of the official identification or grade label to 

 be used. 

 In the event the privilege to use official identification or grade labels on product packaging materials, equipment, 

 utensils, or descriptive or promotional materials is withdrawn in accordance with the appropriate provisions of the 

 aforesaid regulations, the applicant agrees to promptly place under the jurisdiction and control of a USDA licensed 

 grader or design review specialist all packaging materials, descriptive or promotional materials, and other supplies 

 bearing printed reference to the inspected, graded or evaluated character of the products, equipment, or utensils for 

 such subsequent use by the applicant as may be approved by the Administrator. 

 Name, Address and Plant No. (if applicable) of Applicant:

 

 Email Address: 

 If submitting electronically, please sign and mail or fax a copy of this form to: 

 Grade Label Coordinator 

 USDA/AMS/Dairy Programs 

 Dairy Grading Branch 

 Room 2746-S MS 0230 

 1400 Independence Ave. SW 

 Washington, DC 20250-0230 

 Tel: 202-720-3171 

 Fax: 202-720-2643 

 Name and Title of Applicant Representative (Print or Type): 

 Applicant Representative Signature: Date:

 Approval By Chief, Dairy Grading Branch: Date: Control Number:

 

 DA-155 (06-12) Destroy all previous editions.