P&SP 1000 Application for Registration

OMB Control No. 0580-0015

U.S. Department Of Agriculture Grain Inspection, Packers And Stockyards Administration Packers And Stockyards Program

Application for Registration (Under Packers and Stockyards Act, 1921, as Amended and Supplemented)

1. Name of Applicant to Be Registered (Individual or Firm)

2. Trade Name or All Known Aliases

3a. Mailing Address

3b. City 3d. State 3e. Zip

3c. County 3f. Country

4a. Operating Address

4b. City 4d. State 4e. Zip

4c. County 4f. Country

5. Telephone No. 6. Cell Phone No. 7. Fax No.

8. E-Mail Address

9. Web Site Address

10. Type of Livestock Handled (Check All That Apply):

 Cattle  Swine  Sheep and Goats  Horses and Mules

11. Character of Business (Check Applicable Operations):

a. Market Agency:	 Buying on Commission			 Selling on Commission
	 Clearing Service			 Other (Specify)
b. Dealer:	 Buying and Selling
c. Clearee:	 Yes	 No	d. Cleared By:___________________________________________

12a. Type of Organization (Check One)

 Association	 L.L.C.	 Other (Specify)
 Corporation	 L.L.P.
 Individual	 Partnership

12b. State Formed 12c. Date Formed

13a. Owners, Partners, Members, or Officers (Name and Title)	13b. % Ownership	13c. Social Security Number *	13d. Home Mailing Address (Number, Street, City, State, Zip Code)

14. Names and Locations of Posted Stockyards, Auction Markets, Feedlots, and Web Sites Where Applicant Will Operate

15. If Previously Registered, List All Registered Names and Addresses

16. Does Registrant Own/Lease a Scale(s) Used in the Purchase and Sale of

Livestock?

 No  Yes (Give Physical Location of Scale(s); Street,

City, State, Zip Code, Model, and Serial Number)

17. Registrant Will Operate on

 Calendar Year  Fiscal Year Basis: _____________ to _____________

18. If Applicable, Sale Day(s)

 Sun  Mon  Tue  Wed  Thu  Fri  Sat

Market Agency Selling on Commission – Custodial Account Information

19a. Bank 19b. Account No.

19c. Street 19d. City 19e. State 19f. Zip

19g. Telephone 19h. Contact Person

CERTIFICATION I certify that the financial condition of the applicant meets the requirements of the Packers And Stockyards Act, 1921, as amended and supplemented and the application for registration has been prepared by me or under my direction and that to the best of my knowledge and belief this application is true and correct.

20. Signature and Title (Owner, Partner, or Responsible Officer)

21. Date

Space Below: Not to Be Filled In By the Applicant

Registration Number Date of Acceptance

Type of Registration

 Supplemental  Reactivated  New  Amended  RENEWAL

Registered As

 Market Agency  Dealer  Market Agency & Dealer  Brand Inspection

*The Privacy Act of 1974 requires this Agency to inform applicant that disclosures of social security numbers are optional and that the information sought on this form is required by 9 CFR 201.10. The sole use of the social security number(s) sought on this form is to distinguish between applicants and registrants that have identical or similar names. As this Agency maintains a large volume of applications and registrations, applicants are encouraged to supply social security numbers.

Form P&SP-1000 August 2007 Page 2 of 2