* 14,
* 15.
* 16.

* 17.

DIRECTIONS FOR COMPLETION OF FSIS FORM 5200-2 (Continued)
Day/Year Plant Will Operate: Self-explanatory.
Hours/Week Plant Will Operate: Self-explanatory.
Hours/Day Plant Will Operate: Self-explanatory.

Month and Year Plant will be Ready to Operate Under Inspection Program:
Self-explanatory.

* There can be overlapping exempt and non-exempt reporting, e.g., an applicant may have in
section 16, 8 hours exempt and 8 hours non-exempt. This does not necessarily mean the plant

is scheduled
18.
19.

20.

21.

22.

23.

27.
28.
29,
30.
31

to work 16 hours.
Animals Slaughtered: Check applicable block(s).

Fresh Meat or Ready-to-Cook Poultry to be Disposed of in Commerce: Check, _ ‘
applicable block(s)

Prepared or Processed When Inspection is Inaugurated: Check applicable block(s)
for Meat, Poultry, or Both under type of product. If the "Both” block is checked,
indicate whether the activity is for "M", "P", or "B" for entries A through M.
Import Inspection Activities: Fill in only if requesting for Import Inspection and
then the application should be referred to International Programs. (Separate
applications are needed for import requests and domestic requests.)

List of Responsible Persons: Shall include Person signing the application, owners,
Officers, directors, managers, or others in an executive capacity. Be sure to show
name, title, social security number, date and place of birth, home address and check
in the space provided concerning holding of stock.

Person(s) Convicted of a Felony: Self-explanatory, if none, write none.
Convictions Against the Applicants: Self-explanatory.

Sanitation Standard Operating Procedures have been developed: Check applicable block.
Privacy Act Notice: Check appropriate block.

Person Signing Application: Applicant's name should be typed or printed.
Signature: Applicant needs to sign in ink.

Title: Title of applicant whose name appears in Blocks 26 and 27.

Official Number Assigned/Reserved: District Manager will complete.

Plant Presently Under State Inspection: District Manager will complete.

32 through 36: To be completed by USDA.



Collection ofthis information Ie voluntary, is neaded before Faderal inspection of meat ond poultry Is granted. Itis ured by FSIS te determine whether the applicant should te issued a grant of Inspection
Given Sues} ena S CFR IB‘ 10) OM

APPROVED OMB 0583-0082
US, DEPARTMENT OF AGRICULTURE WSTRUCTIONS:
FOOD SAFETY AND INSPECTION SERVICE ‘Submit this application to the District Manager, Faod Safety and Inspection Service, U.S. Department of Agriculture for applicable Inspection requests.
APPLICATION FOR FEDERAL MEAT, Complate all sections. If a section is mot applicable enter “NIA” or “None.” If additional space is needed for any item, sttach sheet and number the item.
POULTRY, OR IMPORT INSPECTION

SECTION | (to be completed for Import or Domestic Inspection Activities)

1. DATE OF APPLICATION 2. TYPE OF APPLICATION <3. TYPE OF INSPECTION REQUIRED “4 EXEMPTED ACTIVITIES
(specity)
mt mi
08/22/2006 C7 gue or [7] sam oF acaron ear mone CS, CP, RE
 otner sspecityy PouLTAY
3. FORM OF ORGANIZATION 6. IF CORPORATION: NAME OF STATE WHERE INCORPORATED
GF aowoun (C7 cooperative association (C1 partners Towa
7. DATE INCORPORATED (Month aad Voor?
cont OTHER,
PORATION [othe speciyy 06/01/2005

‘8, NAME OF APPLICANT (Company Name) AND MAILING ADDRESS flaclude Zip Code) FEDERAL EMPLOYER, Z 8, AREA CODE

.S. Foods, Inc. {As assigned by later c TELEPHONE NUMBER
1234 Main Street

Des Moines, IA 50312 (S15) 111-2222

‘10a. LOCATION OF PLANT AND MAILING ADDRESS IF DIFFERENT FROM ITEM 8 (include Zip Code) ‘ V1. AREA CODE
9876 Oak Avenue MAIL; P.O, Box 444 TELEPHONE NUMBER
Newton, IA 50332 Newton, IA 50332
(641) 888-4321
108, ATTACH A DESCRIPTION OF THE LIMITS OF THE ESTABLISHMENT PREMISES THAT
INSPECTION (0.9., Diagros, written sarrative, or schematic) x "
12, NAME AND ESTABLISHMENT NUMBER OF OTHER ESTABLISHMENTS LOCATED INTHE $B] 19. OTHER NAMES (Hany) UNDER WHICH BUSINESS WILL BE
‘SAME FACILITY SONDUCTED
None merican Pride Meats

f American Pride Poultry

14, DAYS PER YEAR PLANT WiLt | 15. HOURS PER 17, MONTH ANO YEAR WHEN PLANT Witt. GE READY TO OPERATE
OPERATE UNDER

INSPECTION PROL

‘EXEMPT NON-EXEMPT ‘EXEMPT NON-EXEMPT ‘EXEMPT NON-EXEMPT
00 250 2 8 09/01/2006 09/01/2006
‘be completed for Domestic Inspection Activities)
(J soars SWINE (C1 counes

i
a
= YOUNG CHICKENS ( wurnevs (sree (C] pwcks C1 suwers
| 19, FRESH MEAT OR READY-¥0-000 I DISPOSED OF IN COMMERCE 1) _—
lag
ale. BEEF [] vert (CJ tame on morrow (1 coat meat (1 coune meat
: ‘YOUNG CHICKENS ([] mature coucrens ( wxers CL) couse 1 owex {_] ounea
20, PREPARED OR PROCESSED WHEN INSPECTION IS INAUGURATED
TYPE OF PRODUCT [BREAKINGCUTTING (craze prin cats whl pty, poy parte ee) 1h [) CANNING cha tab prise cane. pots
g DF wer [BONING fac bog merypesty? i _] ovine ier cts, bo vt snzage, debe probs)
3 (J route c.[_] MECHANICAL DEBONING pecan bonny meter? i
8 6. [¥] FABRICATING foes stats chops, grand bee, hamburp ate} [| SUCING sean hnctaon meets seusape ete.
4 ©. [1] URN ont te ete ry, am ae) 1 [CT rarsoIs ana tow shoring margaret)
£.[__] FORMULATING restr susie en, oat ale, pat mio) im [_] OTHER spiny

‘COOKINGISMOKING (pe cote, bat cuts. susepe evr etc}

FSIS FORM 5200-2 (7/97) REPLACES FSIS FORM 6200-2 (5/89), WHICH IS OBSOLETE. ‘Decgned on FormFiow software



FSIS FORM 5200-2 (REVERSE)

21, IMPORT INSPECTION ACTIVITIES
1. PROCESSED PRODUCTS: POULTRY (Parts)

1, CARCASSES b. FRESH 1 COOKED REEF FRESHIFROZEN [J aw
(oer C1] venson Cos (LJ restrecteo HEATED [_] cooxen
Cua Co omer (L] sowetess mes wear (J owrestaicren [J oneeoisemtonteo [CJ omer pouttry

(describe (describe)
ome
( steer ©, FROZEN MFG. MEATS ¢. CONTAINERS ‘8. POULTRY (Whole Carcass)
(coats Cours (| penssnaste (| paw
(cone [LJ bonetess mes meat [LJ suetr staste [_] cooxea

SECTION IV (tobe for import aod Domest Activities)
person responsibly connected ae nes pats, fies, TCI, aT or awrer of 10 pa cant mara aig ok, nd enpayes ma Wanapel retCve
opacity nthe business, Noy the District Manager of ay changes inthe at
SOCIAL SECURITY NO. oR y 3S ‘OF 10% OF MORE
name | ay (ci VOTING STOCK Mf Com
Riverside, CA 100 North State e ]
321-99-8877 | 12/12/1965 Minneapolis, 4 L
James Morgan St. Joseph, MO 30022 Maple Court
VicePresiden "SS 453-595-2233 |09/01/1970 St. Paul, MN $5322 y
Paul Steinwick New York, NY Sunset Drive
“Treasures 867-45-6341 ]02/22/1968 ny, TA 50321 v
Richard Vickers ‘Albia, TA
“Pian Manager ~ —| 987-65-4321 |05/29/1963 v

23. Enter the name of each person listed under Item 22 who has been convicted in any Federal or
{ated under tam 22 who has been convict ia my Federal a State cout of more than ow

ing, handling or distributing of unwholesome, misibel

Ince he nature he cme, he date of conviction at

None

Pajelony. y, stench conviction ania te
jon of any la 2 lotony, based upon the aauiing,
Mi aie conection wth atsredons food Include the

24. List each conviction against the applicant (parson, fim or corparation/ in any
‘ant (person, fmm or corporation) in any Federal ge State court of mare

handling, or distributing of unwholesome, mislabeled,
‘ature of the crime, the date of conviction and tha e¢

None

Ow
(] x0

the application, | /we/ expressly agree to conform strictly to the Federal Meat Inspectian Act (27 U.S.C. 601 ot seq, the Regulations Governing the Meat
{Gap Fart 30 tag, Poy Prt inspection A246 So.. nd hm Fty Produ lspactn Reglatns (2 CF 381 e200 ©

ie knowlege ad

audolent statements or entries ae subject ta $10,000 fine or imprisoned not more than fie years oF both as prescribed by Title 18 U.S. Code 1001.

‘AGREEMENT AND CERTEICATION: If inspection gaat
‘inspection of the United States Dopartment of arc

both / CERTIFY that all statements made
WARNING: Persons willy making false, fictitiot

tt igan Eppa roam, yon believe yx hae een sitet eet eae t,o. anna rig a8 ohne, rt Immatinty oeSeretary
Sethe Namiictrator, FSIS, Washington, D202
7 ‘TYPED NAME OF PERSON SIGNING APPLICATION ‘SIGNATURE AND TITLE OF OWNER, PARTNER, OR AUTHORIZED OFFICER MAKING THIS APPLICATION
a 78. SIGNATURE 7a. Tme

Paul Steinwick Treasurer

OFFICIAL NUMBER ASSIGNEDIRESERVE ‘i. IS THIS PLANT PRESENTLY UNDER STATE
i SER ASSIONEORESSAVED \ INSPECTION (Complete by District Otfce?

Clyws  ([)no
TOBE COMPLETED BY USDA

32. OATE RECEIVED: (39. DATE REVIEWED ‘34. THIS PLANT TO BE UNDER TALMADGE-AIKEN ACT

Olws (no

35, SIGNATURE OF DISTRICT MANAGER ‘96. DATE



DIRECTIONS FOR COMPLETION OF FSIS FORM 5200-2

Complete all sections. If a section is not applicable, enter "N/A" or "none". If additional space is needed
for any item, attach a sheet and number the item.

1. Date of Application: Shall be the date on which the form is executed.
2. Type of Application: Check applicable block.
3. Type of Inspection Required: Check applicable block.

4. Exempted Activities: There are several possible entries:
a. Custom Slaughter (CS)
b. Custom Processing (CP)
c. Retail Exempt (includes restaurants) (RE)
d. Kosher (KO) - +
e. Islamic (IS)
f. Buddhist (BU)
g. Confucianist (CO)
An applicant can show one or any combination of the seven, if necessary.

5. Form of Organization: Check applicable block.
6. State Where Incorporated: Self-explanatory.
7. Date Incorporated: Show month and year.

8. Name and address of Applicant: Show official firm name and address. Enter
Federal employee identification number in the space provided.

9. Area Code and Telephone Number: Self-explanatory.

10a. Location of Plant and Mailing Address if Different From Item 8: If the mailing
address of item 8 is a P.O. Box number, show location of the plant by street,
number, miles from town or highway, etc.

10b. Attach a Description of the Limits of the Establishment Premises that is
Requested to be Under Federal Inspection: Self-explanatory.

11. Area Code and Telephone Number: Show Plant's actual telephone number(s).
12. Name and Establishment Number(s) of Other Establishments Located in the Same

Facility: Name of person(s) or firm name(s) and establishment number(s) which
Prepare products within the same facilities of the applicant identified in item 8.

13. Other Names Under Which Business will be Conducted: This refers to subsidiaries
doing business under a different name than the applicant requesting inspection.