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 

APPLICATION FOR 

SERVICE 

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. 

Submit Completed Form to: USDA, MRP, AMS, L&P, QAD Email: New Application 

(Choose one option) Business Operations Branch Telephone: 501-312-2962 Change of Address 

10809 Executive Center Drive, Suite 318 Fax: 1-844-345-3575

: 

 

COMMODITY 

Beef Lamb 

Pork Veal/Calf 

Chicken Turkey 

Rabbit Duck 

Geese 

**Shell Egg 

_________________________________ 

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) 

___________________________________________________________

 

 

Little Rock, AR 72211-6022 

F

 

 

 

 

 

QAD.BusinessOps@usda.gov 

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: 

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) 

Quality Systems Verification Programs (7 CFR Part 62) Grading of Shell Eggs (7 CFR Part 56) 

APPLICANT INFORMATION 

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

Tax ID Number: 

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). 

Small Business: Yes No 

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

E-MAIL ADDRESS:

PHONE NUMBER

PLANT NUMBER: SIS or NFI Est. NUMBER: 

NAME & PHYSICAL ADDRESS WHERE SERVICE(S) WILL BE PERFORMED 

(Street and No., City, State, and ZIP Code) 

: 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: 

FOR OFFICIAL USE ONLY 

DATE: APPROVED BY: 

(Signature) 

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. 

LP-109 (08/2021) Supersedes LPS-109 EXP. DATE: 08/31/2024