Agricultural Quality Assessment Division QAD 100A Appendix 

Marketing 1400 Independence Avenue SW, Stop 0258 October 1, 2021

Service Washington, DC 20250 Page 1 of 3

How to Complete the Application for Service (LP-109) 

1. Place a check mark in the appropriate box to indicate if this is a New Application, Change of 

Address, or Revision.

a. Use New Application if you have not received service before. 

b. Use Change of Address when you are reporting changes in an address for the company. 

c. Use Revision when submitting a form that identifies a change in the company name, 

services requested, etc.

2. Commodity: Place a check mark in the appropriate box to identify ONLY the commodity type 

you are requesting service for at this time. Other commodities that are not listed may be 

identified on the blank line. 

3. Type: Place a check mark in the type of request applicable to the applicant. Check only one 

box. 

a. Scheduled service request is one in which the applicant is entering into an agreement for 

services as outlined in: 

i. 7 CFR Part 54, Meats, Prepared Meats, and Meat Products (Grading, Certification and 

Standards) Section 54.27(c). 

ii. 7 CFR Part 56, Voluntary Grading of Shell Eggs Section 56.28 (b). 

iii. 7 CFR Part 70, Voluntary Grading of Poultry Products and Rabbit Products Section 

70.37(b). 

Scheduled service requests require the submission of Form LP-110, Work Schedule Request 

in addition to the LP-109, Application for Service. 

b. Unscheduled service request is one in which the applicant is entering into an agreement of 

services on an as needed basis or for a warehouse or cold storage facility as outlined in: 

i. 7 CFR Part 54, Meats, Prepared Meats, and Meat Products (Grading, Certification and 

Standards), Section 54.27(c). 

ii. 7 CFR Part 62, AMS Audit Verification and Accreditation Programs, Section 62.202. 

iii. 7 CFR Part 56, Voluntary Grading of Shell Eggs, Section 56.28 (a) or (c). 

iv. 7 CFR Part 70, Voluntary Grading of Poultry Products and Rabbit Products, Section 

70.37 (a) or (c).

c. Other types of service that do not meet the above criteria can be identified on the blank line. 

For audit services, type “Audit Fee.” 
Agricultural Quality Assessment Division QAD 100A Appendix 

Marketing 1400 Independence Avenue SW, Stop 0258 October 1, 2021

Service Washington, DC 20250 Page 2 of 3

4. Grading Services: Place a check mark in the type of services applicable to this Application for 

Service. Multiple boxes may be checked. Other services that do not meet any of the services 

listed can be identified on the blank line. 

5. Auditing Services: If applicable, place a check mark in the type of Auditing Service applicable 

to this Application for Service. Multiple boxes may be checked. Other audit services that do 

not meet any of the services listed can be identified on the blank line. 

6. Regulations Applicable to Requested Service(s): Check the box applicable to this Application 

for Service. Multiple boxes may be checked.

7. Applicant Information: 

a. Name of Applicant. Enter the name of the company requesting service(s). The name 

entered must match the IRS records for the Tax ID Number identified below. 

b. Tax ID Number. Enter the 9 digit IRS Tax Identification number for the company 

requesting service(s). This is the corporate tax identification number sometimes also 

referred to as a Tax Identification Number (TIN) or Employer Identification Number (EIN). 

If the entity submitting the application is an individual, then the social security number is 

required. 

c. Small Business. Is the applicant considered a small business according to the U.S. Small 

Business Administration’s Table of Small Business Size Standards, place a check in the 

appropriate box.

d. Billing Address of Applicant. Enter the address where the invoice(s) for service(s) provided 

should be mailed. 

e. Phone Number. Enter the applicant’s telephone number and fax number (if applicable). 

f. E-mail Address. Enter the e-mail address of the representative that completed the form.

g. Plant Number. For poultry and shell egg plants, enter the official plant number if a plant 

number has already been assigned. If this is a new poultry or shell egg plant requesting 

service and does not have a plant number assigned, leave this field blank. It will be assigned 

by the Business Operations Branch.

h. FSIS or NFI Establishment Number. If applicable, enter the FSIS or NFI establishment 

number where service will be performed.

i. Name and Physical Address Where Service(s) Will Be Performed. Enter the address of the 

location where service(s) will be performed. In instances where the entity requesting 

services is different than the entity where service(s) are provide, include the name of the 

company.
Agricultural Quality Assessment Division QAD 100A Appendix 

Marketing 1400 Independence Avenue SW, Stop 0258 October 1, 2021

Service Washington, DC 20250 Page 3 of 3

j. Phone Number. Enter the telephone number available at the physical address and fax 

number (if applicable). 

8. ** Certification: If the applicant is requesting Shell Egg service(s), place a check mark in the 

box to acknowledge agreement with the certification statement.

9. I (We) agree to: Place a check mark in the box to acknowledge agreement with the statements. 

CFR’s can be found: 7 CFR 54, 7 CFR 56, 7 CFR 62, 7 CFR 70, and PL 272 can be found here. 

10. Print Name & Title of Applicant: Enter the printed name and printed title of the representative 

submitting the application. 

11. Signature of Applicant: Enter the signature of the representative completing application. 

Include a contact number by the signature. 

12. Date: Enter date the application was signed.

13. Submit Completed Application for Service to:

USDA, MRP, AMS, L&P, QAD

Business Operations Branch

10809 Executive Center Drive, Suite 318 

Little Rock, AR 72211-6022 

QAD.BusinessOps@usda.gov

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and 

employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, 

gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance 

program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all 

programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) 

should contact the responsible Agency or USDA's TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 

877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at How to File a Program 

Discrimination Complaint and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request 

a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the 

Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: 

program.intake@usda.gov. 

USDA is an equal opportunity provider, employer, and lender.