LS-313 Application for Service

FORM APPROVED – OMB NO. 0581-0124

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

U.S. Department of Agriculture
Agricultural Marketing Service
Livestock and Seed Program

Grading and Verification Division
USDA, MRP, AMS, LSP, GV Division
13952 Denver West Parkway
Building 53, Suite 350
Lakewood, CO 80401

Application for Service

Fax:
Email:

720-497-0571
[email protected]

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 0581-0124. The time to complete this information collection is estimated to average 6 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) or Employer Identification Number (EIN) is mandatory, and will be used to determine affiliation or entity identity. Please note that background statements will not become invalid if a TIN or EIN is not disclosed.

The undersigned hereby applies to the Grading and Verification Division, Livestock and Seed Program, U.S. Department of Agriculture, for the furnishing of official services to be provided at
the following location:

Name of Applicant:

Tax ID Number (Required by IRS). Corporate
Tax ID number unless Applicant is an Individual,
then Social Security Number.

Billing Address (Include P.O. Box or Street, City,

Physical Address of Service Location (no

State, and Zip Code)

P.O. Box)

Telephone Number
Fax Number
Email Address

Grading Services

Verification Services

Type of Service Required (Check all that apply)

Type of Service Required (Check all that apply)

Carcass Grading (check applicable species)
Beef
Pork
Veal/Calf
Product Certification
Processing
Product Examination Service

Process Verified Program (PVP)
Quality System Assessment Program

Lamb

(QSA) Export Verification (EV) Program
Non-Hormone Treated Cattle (NHTC)

Carcass Grade Factor Further
Meat Judging Contest

Program Pork for the European Union (PFEU)
Program USDA ISO Guide 65 Program
National Organic Program (NOP)

Other (Specify)

Seed Accreditation Programs (ASL, AFIP, ASSP)
Other (Specify)

Inspection Information:

FSIS Est. No.

Operations Conducted:
Slaughter (Identify Species)
Processing

Fabrication

Legal Status (Check One)

Cattle
Distribution

Individual Owner

Corporation

or

Veal

Calves

Breeding

Sheep

Swine

Support Services

Partnership

NFI Est. No.
Bison

Marketing

Financial Interest In
Product:

Other (Specify)

Goats
Feeding

Other
Other

Owner/Part Owner

Other

Contractor

I (We) agree to:

I (We) agree to:

1. To comply with all applicable provisions of the Federal Meat Grading and Certification
Regulations, 7 CFR, Part 54 (Revised), a copy of which I (we) have received and read;
2. To notify the Customer Service Director, in writing and in advance of my (our)
cancellation of this application;
3. To notify the Customer Service Director immediately when a change occurs in my (our) legal
status/Applicant Representative; and
4. That the Federal meat grading certification service for which application is hereby made may
be denied or withdrawn at any time as provided in the Federal Meat Grading and
Certification Regulations

1. To comply with all applicable provisions of the Quality Systems Verification Programs, 7
CFR, Part 62, a copy of which I (we) have received and read;
2. To notify the Audit, Review, and Compliance Branch in writing and in advance of my (our)
cancellation of this application;
3. To notify the Audit, Review, and Compliance Branch immediately when a change occurs in my
(our) status/Applicant Representative; and
4. That the quality system verification service for which application is hereby made may be denied
or withdrawn at any time as provided in the Quality Systems Verification Programs.

Signature of Applicant or Representative

Date

Print or Type Name of Signee
Title of Signee
Information provided in this application is needed to authorize USDA employees to perform the requested service (7 CFR 54, 6, & 7 CFR 62). You may by law, be fined up to $10,000, imprisoned up to 5 years, or both for
knowingly or willfully making false statements within this document (18 U.S.C. Section 1001).

Date Of Approval

LS-313 (11-2011)

Title of Approving Officer

For Official Use
Signature of Approving Officer

Previous editions must be destroyed.