P&SP 1100 Application for Registration - Packer Buyer

U.S. Department of Agriculture Grain Inspection, Packers and Stockyards Administration Packers and Stockyards Program

Application for Registration Packer Buyer Buying Only for Slaughter as an Employee of a Meat Packer (Under the Packers and Stockyards Act, 1921, as Amended and Supplemented)

Please Print or Type

(1) Name of Applicant to Be Registered (Individual or Firm)						(2)
(3a) Mailing Address
(3b) City							(3c) State	(3d) Zip Code
(4a) Operating Address (if different from mailing address listed above)
(4b) City							(4c) State	(4d) Zip Code
(5a) County			(5b) Country
(6) Telephone No.		(7) Cell No.			(8) Fax No.
(9) E-mail Address
(10) Livestock to Be Purchased (check all that apply)
 Feeder Cattle  Fed Cattle  Steers and Heifers		 Cows and Bulls  Calves  Swine			 Sheep and Goats  Horses and Mules
(11) Names and locations of posted stockyards, feedlots, or web sites where you will purchase livestock
(12) If you operate a buying station for your employer, list name and location
(13) If previously registered, list all registered name(s) and address(es)
(14a) Do you own an interest in other dealer organization(s), market agency(s), stockyard company(s), or packing company(s)?
 Yes (complete table below)				 No (go to item 15 in the form)
(14b) Name of other Organization	(14c) Location (City, State, Zip Code)							(14d) Percent of Control by Applicant

Certification: To the best of my knowledge and belief, the foregoing statements are true and correct.
(15a) Signature of Applicant		(15b) Title (if any)		(15c) Date
For Completion By Packer-Employer
The above applicant is employed by our firm to buy the livestock identified in item no. 10 for slaughter purposes only.
(16a) Signature		(16b) Official Title
(16c) Name of Firm			(16f) Date
(16d) Address
(16e) Telephone No.
Do Not Complete: For Official Use Only
Registration No.	Registered As
Dealer
Remarks

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.

Registration is required in order to operate as a market agency or dealer as defined in Section 301 (7 U.S.C. 201) of the Packers and Stockyards Act, 1921, as amended and supplemented and 9 CFR 201.10 (a). Information held confidential (9 CFR 201.96).

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information is 0580-0015. The time required to complete this information collection is estimated to average .50 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.

Form P&SP-1100 August 2007 Page 2 of 2