LPS-110 Work Schedule Request (paper vers.)

OMB APPROVED: OMB NO 0581-0128
REPRODUCE LOCALLY. Include form number and edition on all reproductions.
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
U.S. DEPARTMENT OF AGRICULTURE
collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is
AGRICULTURAL MARKETING SERVICE
0581-0128. The time required to complete this information collection is estimated to average 15 minutes per response, including the time for
LIVESTOCK, POULTRY, AND SEED PROGRAM reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
of information.
QUALITY ASSESSMENT DIVISION

WORK SCHEDULE REQUEST

Submit Completed Form:

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.

USDA, MRP, AMS, LPS, QAD
Business Operations Branch
10809 Executive Center Drive, Suite 318
Little Rock, AR 72211-6022

E-mail: [email protected]
Telephone: 501-312-2962

Fax: 501-312-2968

Regulations Applicable to the Requested Services
Voluntary Grading of Shell Eggs (7CFR Part 56)

Meats, Prepared Meats, and Meat Products (Grading, Certification, and Standards) (7CFR Part 54)

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

Livestock, Meat, and other Agricultural Commodities (Quality Systems Verification Programs)
(7CFR Part 62)

The provisions of the above selected Regulations shall be applicable to this application and the signers thereof. The days and number of hours shown below will
be established as the normal work schedule for this plant(s). The firm may terminate the application at their discretion, effective at close of business on any
Saturday, by giving written notice to the Business Operations Branch at least 30 days prior to such Saturday. The following hours of service are requested for this
agreement.
Firm Name:

FSIS/Plant Number:

Service Request Hours (Total Hours Per Day/Shift)

Location of Service Address:
Sunday

Date:

Title of Firm Representative:

Monday

Title of Firm Representative:

Monday

Tuesday

Signature of Firm Representative:

Firm Name:

Sunday

Saturday

Total Hours

Saturday

Total Hours

Miles:

Wednesday Thursday

Friday

E-mail Address:

Miles:

Title of Firm Representative:

Monday

Tuesday

Signature of Firm Representative:

Wednesday Thursday

Friday

E-mail Address:

Night Differential:

Special Provisions

FOR OFFICIAL USE ONLY

LPS-110 (02-2015)

Total Hours

Service Request Hours (Total Hours Per Day/Shift)

Location of Service Address:

Effective Date of Agreement:

Saturday

E-mail Address:

FSIS/Plant Number:

Regular:

Friday

Service Request Hours (Total Hours Per Day/Shift)
Sunday

Holiday Hours
(If applicable)

Wednesday Thursday

FSIS/Plant Number:

Location of Service Address:

Date:

Tuesday

Signature of Firm Representative:

Firm Name:

Date:

Miles:

Signature of Approving Official:

Date Signed: