LS313 eform versio Application for Service

Cancel

Reproduce Locally. Include form number and edition date on all reproductions.

U.S. Department of Agriculture
Agricultural Marketing Service
Livestock and Seed Program

Meat Grading and Certification Branch
Fax:
720-497-0571
Email:
[email protected]

Application for Service

USDA, MRP, AMS, LSP, MGC Branch
13952 Denver West Parkway
Bldg. 53, Suite 350
Lakewood, CO 80401

FORM APPROVED – OMB NO. 0581-0124

Audit, Review and Compliance Branch
Fax:
202-690-1038
Email:
[email protected]
Phone:
540-361-7640
USDA, MRP, AMS, LSP, ARC Branch
100 Riverside Parkway, Suite 135
Fredericksburg, VA 22406

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 0581-0124. The time to complete this information collection is estimated to average 12 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 and employer. NOTE: The following statements are made in accordance with the
Privacy Act of 1974 (U.S.C. 522a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting this information to be supplied on this form is the Agricultural Marketing Agreement Act of 1937, Secs.
1-19, 48 Stat. 31, as amended, (7 U.S.C. 601-674). Furnishing the requested information is necessary for the administration of this program. Submission of the Tax Identification Number (TIN) or Employer Identification
Number (EIN) is mandatory, and will be used to determine affiliation or entity identity. Please note that background statements will not become invalid if a TIN or EIN is not disclosed.

The undersigned hereby applies to either the Meat Grading and Certification Branch, Livestock and Seed Program, or the Audit, Review and Compliance Branch, Livestock and Seed Program,
U.S. Department of Agriculture, for the furnishing of official services to be provided at the following location:

Name of Applicant:

Tax ID Number (Required by IRS). Corporate
Tax ID number unless Applicant is an Individual,
then Social Security Number.

Billing Address (Include P.O. Box or Street, City, State,

Physical Address of Service Location (no P.O.

and Zip Code)

Box)

Telephone Number
Fax Number
Email Address

Meat Grading and Certification Branch Services

ARC Branch Services

Type of Service Required (Check all that apply)

Type of Service Required (Check all that apply)

Carcass Grading (check applicable species)
Beef
Pork
Veal/Calf
Product Certification
Further Processing
Product Examination Service
Other (Specify)

Process Verified Program (PVP)
Quality System Assessment Program (QSA)
Export Verification (EV) Program
Non-Hormone Treated Cattle (NHTC) Program
Pork for the European Union (PFEU) Program
USDA ISO Guide 65 Program
National Organic Program (NOP)

Lamb

Carcass Grade Factor
Meat Judging Contest

Seed Accreditation Programs (ASL, AFIP, ASSP)
Other (Specify)

Inspection Information: FSIS Est. No.
Operations Conducted:
Slaughter (Identify Species)
Cattle

or

Veal

Calves

Sheep

Swine

NFI Est. No.
Bison

Processing Fabrication Distribution Breeding Support Services Marketing
Legal Status (Check One)
Individual Owner Partnership
Financial Interest In
Corporation Other (Specify)
Product:
I (We) agree to:

Goats
Feeding

Other_____________
Other________________
Other (Specify)
Owner/Part Owner
Contractor

I (We) agree to:

1. To comply with all applicable provisions of the Federal Meat Grading and Certification
Regulations, 7 CFR, Part 54 (Revised), a copy of which I (we) have received and read;
2. To notify the Customer Service Director, in writing and in advance of my (our) cancellation
of this application;
3. To notify the Customer Service Director immediately when a change occurs in my (our) legal
status/Applicant Representative; and
4. That the Federal meat grading certification service for which application is hereby made may
be denied or withdrawn at any time as provided in the Federal Meat Grading and Certification
Regulations

1. To comply with all applicable provisions of the Quality Systems Verification Programs, 7 CFR,
Part 62, a copy of which I (we) have received and read;
2. To notify the Audit, Review, and Compliance Branch in writing and in advance of my (our)
cancellation of this application;
3. To notify the Audit, Review, and Compliance Branch immediately when a change occurs in my
(our) status/Applicant Representative; and
4. That the quality system verification service for which application is hereby made may be denied or
withdrawn at any time as provided in the Quality Systems Verification Programs.

Signature of Applicant or Representative

Date

Print or Type Name of Signee
Title of Signee
Information provided in this application is needed to authorize USDA employees to perform the requested service (7 CFR 54, 6, & 7 CFR 62). You may by law, be fined up to $10,000, imprisoned up to 5 years, or both for
knowingly or willfully making false statements within this document (18 U.S.C. Section 1001).

Date Of Approval

LS-313 (11-2007)

Title of Approving Officer

For Official Use Only
Signature of Approving Officer

Previous editions must be destroyed.

Clear Form

Print Form

Submit & Close