PY-212 Retail Quality Program Agreement

REPRODUCE LOCALLY. Include form number and edition date on all reproductions.
U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
POULTRY PROGRAMS

RETAIL QUALITY PROGRAM
AGREEMENT

FORM APPROVED - OMB No. 0581-0127

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, inlcuding the time for reviewing instructions, searching existing data
sources, gathering and maintaining 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 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.

I (We) _____________________________________________________ hereby request to participate in the RETAIL QUALITY
PROGRAM (RQP) in accordance with the applicable provisions of the guidelines and regulations issued by the Agricultural
Marketing Service (AMS), U.S. Department of Agriculture, to be performed at the facilities specified (attached) and hereby agree
to comply with such provisions and the terms of this agreement (including but not limited to instructions governing such service
that may be issued from time to time, by AMS). I (We) hereby acknowledge receipt of Public Law 84-272 (7 U.S.C. 1622(h))
and applicable instructions under which this agreement is made. I (We) also agree to pay for the services rendered and all
related travel expenses incurred while performing such services. The services specified below shall start on _________________.
TYPE OF SERVICE REQUESTED
OPTIONAL SERVICES

TYPE OF SERVICE REQUESTED

LEVEL 1 - INTERMITTENT BASIS

1. BIOLUMINESCENCE TESTING

LEVEL 2 - CONTINUOUS BASIS

2. QUALITY EVALUATION OF POULTRY/SHELL EGGS

LEVEL 3 - MARKETING BASIS

3. FOOD SERVICE EMPLOYEE TRAINING
4. MICROBIOLOGICAL AND CHEMICAL TESTING
5. FAT ANALYSIS OF MEAT PRODUCTS
6. OPERATIONAL PROCEDURES VERIFICATION
7. OTHER

*NAME AND ADDRESS OF CORPORATE OFFICE (Street and No., City
State, and ZIP Code)

DESIGNATED CORPORATE CONTACT PERSON
Name _______________________________________________________
Title ________________________________________________________

The above designated contact person will furnish each Quality Inspector (QI) with such information as may be necessary for
the performance of the service and to whom the QI or program representative shall address comments, suggestions, or other
pertinent information required to maintain compliance with the program. The designee will receive copies of the inspection
report for each facility and will be contacted quarterly, or as necessary, regarding program status and other pertinent issues.
The NAME AND ADDRESS of each facility designated to participate in the retail program must be attached with signature and
date by the CORPORATE CONTACT PERSON. Also include the names and titles of each STORE CONTACT PERSON.
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.)
DATE

SIGNATURE

APPLICATION GRANTED BY
(For use by USDA)
DATE

TITLE

AGRICULTURAL MARKETING SERVICE
BY (Signature)

* No member of or delegate to Congress, or Resident Commissioner, shall be admitted any benefit that may arise from this service unless derived through service
rendered a corporation for its general benefit.

PY-212 (03-10) (Destroy previous editions.)