Request for Cooperative Pool Mfg. Plant System Status

UNITED STATES DEPARTMENT OF AGRICULTURE
Address: XXX
XXX
Phone: XXX
Fax: XXX
E-mail: XXX

AGRICULTURAL MARKETING SERVICE
DAIRY PROGRAM
XXX FEDERAL MILK ORDER XXX

Request for Cooperative Pool Manufacturing Plant System Status

Note: This cover page is for information purposes only and does not need to be submitted to the market administrator's office.

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
0581-0032. 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.
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UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
DAIRY PROGRAM

Address: XXX
XXX
Phone: XXX
Fax: XXX
E-mail: XXX

Form Approved, OMB No. 0581-0032

XXX FEDERAL MILK ORDER XXX

Request for Cooperative Pool Manufacturing Plant System Status
Date:
To:

Market Administrator

From:
(Cooperative Handler Name which is Responsible for System)

Subject:

Request for Cooperative Pool Manufacturing Plant System Status

The cooperative(s) listed in Section 2 hereby request(s) pool plant status for the plants identified below:
Section 1: Sequence of Cooperative Manufacturing Plants Within System
Plant Names
Affiliation*
City

State

* Abbreviated cooperative name.

Section 2: Names/Signatures of Cooperative Representatives Within System
Cooperative Name
Name of Representative/Title**
Signature

** Persons signing System forming document must be authorized to sign reports.

Section 3: Effective Date
Month:

Year:

Date