PY-32 Application for Service

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Include form number and edition date on all reproductions.

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

APPLICATION FOR
SERVICE

OMB APPROVED - 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, 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.

In accordance with the applicable provisions of the regulation issued by the Agricultural Marketing Service, U.S. Department of Agriculture,
application is hereby made for the furnishing of the service(s) checked below to be performed at the plant specified:
"X"

VOLUNTARY SERVICE REQUESTED

TYPE OF SERVICE

REGULATIONS APPLICABLE TO SERVICE REQUESTED

Resident

SHELL EGG GRADING SERVICE

Non-Resident

Grading of Shell Eggs (7 CFR Part 56)

Temporary
Resident

POULTRY OR RABBIT GRADING SERVICE

Non-Resident

Voluntary Grading of Poultry Products and Rabbit Products (7 CFR Part 70)

Temporary
NAME, ADDRESS, TELEPHONE NUMBER, AND FAX NUMBER OF PLANT (Street and No., City, State, and ZIP Code)

PLANT NUMBER

CERTIFICATION: I agree to comply with the terms and conditions of the regulations applicable to the service(s) requested (including
but not limited to such instructions governing such service as may be issued, from time to time, by the Agricultural Marketing Service).
I also agree to notify the Agricultural Marketing Service of any contaminated or adulterated (chemical, physical, or biological agents)
shell eggs in the processing plant and to assure identification and segregation of such product. This notification includes shell eggs
that have tested positive for Salmonella Enteritidis (SE) or shell eggs from houses determined positive for the presence of SE, or any
shell eggs that have been recalled or subject to any recall. I also agree to provide the AMS grader detailed information pertaining to
the method of identification and segregation required of any shell eggs that have been determined to be contaminated, or adulterated,
including eggs from an identified layer flock that tests positive for the presence of SE. I hereby acknowledge receipt of a copy of
Public Law 84-272 (7 U.S.C. 1622(h)) and the regulations under which this application is made.
NAME (As shown on your income tax return)

ADDRESS OF APPLICANT (Street and No., city, State, and ZIP Code)

NAME OF APPLICANT (If different from above)

E-MAIL ADDRESS:

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).
SIGNATURE OF APPLICANT

DATE

APPLICATION GRANTED
(FOR USE BY USDA, Agricultural Marketing Service)
DATE

TITLE

BY (Signature)

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

PY-32 (xx/xx) (Previous editions must be destroyed.)