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

U.S. DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

Livestock and Poultry Program

Quality Assessment Division

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.

WORK SCHEDULE REQUEST

Submit Completed Form to:

(Choose one option)

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)

Quality Systems Verification Programs (7 CFR Part 62)

Grading of Shell Eggs (7 CFR Part 56)

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: Miles: 

Location of Service Address: Sunday Monday Tuesday Wednesday Thursday Friday Saturday Total Hours

Date: Title of Applicant Representative: Signature of Applicant Representative: Email Address:

Applicant Name: FSIS/Plant Number: Miles: 

Location of Service Address: Sunday Monday Tuesday Wednesday Thursday Friday Saturday Total Hours

Date: Title of Applicant Representative: Signature of Applicant Representative: Email Address:

Applicant Name: FSIS/Plant Number: Miles: 

Location of Service Address: Sunday Monday Tuesday Wednesday Thursday Friday Saturday Total Hours

Date: Title of Applicant Representative: Signature of Applicant Representative: Email Address:

SPECIAL PROVISIONS:

FOR OFFICIAL USE ONLY

Effective Date of Agreement:

(Sunday only) 

Approved By:

(Signature)

Date Signed:

LP-110 (08/2021) Supersedes LPS-110 EXP. DATE: 08/31/2024