Application for Service

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U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
POULTRY PROGRAMS

APPLICATION FOR
SERVICE

OMB APPROVED - NO. 0581-0127

The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a) & the Paperwork Reduction Act of 1995. The authority
for requesting the information to be supplied on this form is the Agricultural Marketing Act of 1946, as amended (7 U.S.C. 1621- 1627). The
application serves as the basis for a written agreement/contract for continuous resident grading service (7 CFR 56.21(b) and 70.31(b)). 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 0581-0127. 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 the USDA's
TARGET Center at 202-720-2600 (voice and TDD).
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400
Independence Avenue, SW, Washington, DC 20250-9410 or call 800-795-3272 (voice) or 202-720-6382 (TDD). USDA is an equal opportunity
provider and employer.

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:
"X"

VOLUNTARY SERVICE REQUESTED

TYPE OF SERVICE

REGULATIONS APPLICABLE TO SERVICE REQUESTED

Resident

SHELL EGG GRADING SERVICE

Grading of Shell Eggs (7 CFR Part 56)

Non-Resident
Temporary
Resident

POULTRY OR RABBIT GRADING SERVICE

Voluntary Grading of Poultry Products and Rabbit Products (7 CFR Part 70)

Non-Resident
Temporary

NAME, ADDRESS, TELEPHONE NUMBER, AND FAX NUMBER OF PLANT (Street and No., City, State, and ZIP Code)

PLANT NUMBER

CERTIFICATION: I agree to comply with the terms and conditions of the regulations applicable to the service(s) requested (Including
but not limited to such instructions governing such service as may be issued, from time to time, by the Agricultural Marketing Service)
I hereby acknowledge receipt of a copy of Public Law 84-272 (7 U.S.C. 1622(h)) and the regulations under which this application is
made.
NAME OF APPLICANT*

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

E-MAIL ADDRESS:

EMPLOYER IDENTIFICATION NUMBER (EIN)

(is a 9 digit number assigned to sole proprietorships, corporations, partnerships,

estates, trusts, and other entities for filing and reporting purposes).
SIGNATURE OF APPLICANT

DATE

APPLICATION GRANTED
(FOR USED BY USDA, Agricultural Marketing Service)
DATE

TITLE

BY (Signature)

*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.

PY-32 (11/07) (Destroy previous editions.)