Form DA-228 Request for Applicant Number

FORM APPROVED - OMB NO. 0581-NEW

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

Dairy Grading Program
Fax:
630-437-5060
Email:
[email protected]

U.S. Department of Agriculture
Agricultural Marketing Service
Dairy Program

Mail To:

Request for Applicant Number

USDA, AMS, DAIRY
2150 Western Ct.
Suite 100
Lisle, IL 60532

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-NEW. The time to complete this information collection is estimated to average X 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) is mandatory, and will be used to determine affiliation or entity identity.

1. COMPANY NAME:
AS REGISTERED WITH IRS
2. DOING BUSINESS AS NAME:
IF APPLICABLE
3. FEDERAL TAX ID NUMBER:
4. BILLING ADDRESS LINE 1:

Attn: Accounts Payable (A/P)

5. ADDRESS LINE 2:
6. CITY:

STATE:

7.

A/P CONTACT:

8.

A/P PHONE:

9.

A/P FAX:

ZIP+4:
EXT:

10. A/P E-mail ADDRESS:
COMPANY
11. P.O. BOX and/or
MAILING
STREET ADDRESS
ADDRESS
(if different than
Billing address)
12. CITY, ST ZIP (+4)
13. CONTACT FOR MAILING ADDRESS
(if different than Billing):
14. E-MAIL FOR CONTACT
(if different than Billing):
Requested By:
Date Requested:

Expedite
*Expedite fee at 1 hour inspection rate will be applied to account.

Service Types That Will Be Needed (Check All That Apply)
Grading Certificates
Export Certificates
COMMENTS:

DA-228

Plant Approval Status
Equipment Inspectiion