Application for License

FORM APPROVED OMB NO. 0581-0128

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

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 0581-0128. The time required
to complete this information collection is estimated to average 0.5 hours 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.

APPLICATION FOR LICENSE

SECTION A: (To be completed by applicant.)
REQUEST FOR LICENSE: In accordance with the regulations cited, I hereby apply for a license as:
SHELL EGG GRADER (7 CFR Part 56)

POULTRY OR RABBIT GRADER (7 CFR Part 70)

SHELL EGG SURVEILLANCE INSPECTOR (7 CFR Part 57)

AUDITOR

NAME AND ADDRESS OF APPLICANT (First, middle initial(s), and last) Please Print

NAME AND ADDRESS OF CURRENT EMPLOYER (Name, Street, City, State, and Zip)

HAVE YOU BEEN PREVIOUSLY LICENSED BY USDA? If "YES" give year and state in which you were licensed and products you were licensed to grade, inspect, or audit.
NO

YES ________________________________________________________________________________________________

ARE YOU A CITIZEN OR NATIONAL BY BIRTH OF THE UNITED STATES OR U.S. TERRITORY/POSSESSION AND AT LEAST 18 YEARS OF AGE?
NO

YES

CERTIFICATION

This is to certify that I agree, as a condition to the granting of the license applied for, to faithfully carry out the duties assigned to me as a licensee of the U.S.
Department of Agriculture; and I will, to the best of my ability, properly apply and abide by the standards, grades, and/or requirements for operation as set
forth in applicable laws, regulations, and instructions. I hereby acknowledge receipt of a copy of Public Law 84-272 (7 U.S.C. 1622(h)) and the regulations
applicable to the license applied for. If my license is suspended or revoked, I will immediately surrender it to an appropriate USDA official. I further certify
that the statements made by me in the application are true, complete, and correct to the best of my knowledge and belief.
BEFORE SIGNING THIS APPLICATION SIGNATURE OF APPLICANT (Please sign in ink)
CHECK BACK OVER IT TO BE SURE
THAT YOU HAVE ANSWERED ALL
QUESTIONS CORRECTLY.

DATE

PRIVACY ACT NOTICE
Authority to collect personal information -- This information is provided pursuant to Public Law 93-579, Privacy Act of 1974 (5 USC 552a), December 31, 1974 and the
Paperwork Reduction Act of 1995, for individuals applying for U.S. Department of Agriculture licenses as shell egg graders, poultry graders, rabbit graders, shell egg surveillance
inspectors, and auditors. Section 1622(h) of Title 7 of the United States Code gives the U.S. Department of Agriculture the authority to inspect, certify, and identify the class,
quality, quantity, and condition of agricultural products involved in interstate commerce. Sections 1031-1056 of Title 21 of the United States Code require the U.S. Department of
Agriculture to provide an inspection program to control the disposition of dirty and checked shell eggs; and to control unwholesome, adulterated, and inedible egg products and
shell eggs that are unfit for human consumption (7 CFR 56.10, 59.110, and 70.20(a) and (b)). Use of the application for license form is necessary to obtain personnel to perform
these functions.
Purpose and uses -- the principal purpose of the application for license form is to collect information needed to determine qualifications and suitability of applicants seeking to
become licensees of the U.S. Department of Agriculture. Your completed application form will be used to determine whether or not the license applied for will be granted to you.
All or part of your completed application for license form may be disclosed outside of the U.S. Department of Agriculture to:
1. Appropriate Federal, State, or local law enforcement agencies charged with the responsibility of investigating a violation of potential violation of law.
2. A court, magistrate, or administrative tribunal, or opposing counsel in a proceeding before any of the above, if your application constitutes evidence in that proceeding, or is
sought in the course of discovery.
3. Appropriate Federal, State, or local agencies maintaining records on you to obtain information relevant to an agency decision about you.
4. A requesting Federal, State, or local agency to the extent the information is relevant to the requesting agency's decision about you.
5. A congressional office in response to an inquiry from the congressional office made at your request.
Effect of nondisclosure -- Failure to correctly complete all items may result in the rejection of your application for license.
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.
PY-157 (11-07) (Destroy all previous editions.)

SECTION B: FOR USE BY USDA
COMPARATIVE GRADINGS -- POULTRY, RABBITS, AND SHELL EGGS
GRADER

CLASS

AA

A

B

B*

C

D

CK

LOSS

NO
GRADE

SCORE

APPLICANT
SUPERVISOR
APPLICANT
SUPERVISOR
APPLICANT
SUPERVISOR
APPLICANT
SUPERVISOR
APPLICANT
SUPERVISOR
APPLICANT
SUPERVISOR
APPLICANT
SUPERVISOR
APPLICANT
SUPERVISOR
APPLICANT
SUPERVISOR
APPLICANT
SUPERVISOR
APPLICANT
SUPERVISOR
REMARKS:

Licence Card Number:

Effective Date of License:

Date Transmitted To Supervisor:

Date Transmitted To Licensee:

CONCURRENCE AND APPROVAL
I have examined this application
and hereby recommend the
applicant for the license requested.

SIGNATURE OF SUPERVISOR (Please sign in ink)

SIGNATURE OF REVIEWING OFFICIAL
PY-157 (11-07) (Destroy all previous editions.)

DATE

DATE