PSD- 1100 Application for Registration - Packer Buyer

OMB Control No. 0581-0308
U.S. Department of Agriculture
Agricultural Marketing Service
Fair Trade Practices Program
Packers and Stockyards Division

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)

1.

Name of Applicant to Be Registered (Individual or Firm)

2a.

Mailing Address

2b.

City

3a.

Operating Address (If different from mailing address listed above)

3b.

City

3c. County

4.

Telephone

5.

7.

E-Mail Address

8.

Type of Livestock To Be Purchased for Slaughter (Check all that Apply)

9.

2c. County

2d.

3d.

Cell Phone

Steers and Heifer

Swine

Cows and Bulls

Sheep and Goats

Calves

Horses and Mules

State

2e. Zip+4

State

3e. Zip+4

6.

Fax

Names and Locations of Posted Stockyards, Feedlots, or Web Sites where you will purchase livestock

10. If you operate a buying station for your employer, list name, city, state and zip +4

11. If previously registered list all registered name(s) and address(es)

12. Do you own an interest in other dealer organization(s), market agency(s), stockyard company(s), or packing company(s)? If yes, complete the table below. If
not, go to item no. 13 in the form.
Yes
12a. Name of other Organization

Form PSD 1100

No
12b. Location (City, State, Zip+4 Code)

Expires 02/28/2021

12c. % Control by
Applicant

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OMB Control No. 0581-0308
CERTIFICATION: With my signature, I certify the information provided on this form is tue and correct to the best of my knowledge
and belief I am an owner, officer, or have been authorized by responsible management to certify this report.
13a. Signature of Applicant:

13b. Print name of Applicant:

13c.

Date:

PACKER EMPLOYER
CERTIFICATION: The above applicant is employed by our firm to buy the livestock identified on line 8 for slaughter purposes only.
14a. Signature of Employer:

14b. Print name:

14c.

Date:

15. Official Title:
16. Name of Firm:
17. Address:

18. Telephone:

19. Email Address:

20. Website, if applicable:
Do Not Complete: Completed by Packers & Stockyards Division

Registration No.
Date of Acceptance

Remarks:

Registration is required in order to operate as a market agency or dealer subject to 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, 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 is 0581-0308. The time required to complete
this information collection is estimated to average 1.50 hours 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.
In accordance with Federal law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, this institution is prohibited from discriminating
on the basis of race, color, national origin, sex, age, disability, and reprisal or retaliation for prior civil rights activity. (Not all prohibited bases apply to all
programs.) Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American
Sign Language, etc.) should contact the responsible State or local Agency that administers the program or USDA’s TARGET Center at (202) 720-2600 (voice and
TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information is also available in languages other than English.
To file a complaint alleging discrimination, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at
http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office or write a letter addressed to USDA and provide in the letter all of the information
requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (a) mail: U.S. Department
of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (b) fax: (202) 690-7442; or
(c) email: [email protected].

Form PSD 1100

Expires 02/28/2021

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Instructions to Complete
Application for Registration
Packer Buyer
Form PSD 1100
Applicants employed by a packer on salary or other compensation and buying livestock for such packer use
form PSD 1100 to register as a packer buyer. If any information is missing or incorrect, the Packers and
Stockyards Division (PSD) will return the application form to the principal for completion or correction.
Operating without proper registration and bond may subject the principal to penalties including a fine of
$1,913.00 for each violation and not more than $96.00 for each day it continues.
After completing the application for registration, the applicant should retain the original and must send a fully
executed copy with original signature to the Regional Office of PSD that covers your state as listed at the top
of this document.
Submit the completed form to the regional office of PSD as listed below. The states, provinces and territories
covered by each regional office are listed below the regional office’s address.
Regional Offices of the Packers and Stockyards Division
Agricultural Marketing Service, Fair Trade Practices Program
Atlanta Regional Office
Denver Regional Office
Des Moines Regional Office
75 Ted Turner Drive SW, Ste 230 3950 Lewiston St., Suite 200
210 Walnut Street, Room 317
Atlanta, GA 30303-3308
Des Moines, IA 50309-2110
Aurora, CO 80011-1556
Telephone: (404) 562-5840
Telephone: (303) 375-4240
Telephone: (515) 323-2579
FAX: (404) 562-5848
FAX: (515) 323-2590
FAX: (303) 371-4609
e-mail:
e-mail:
e-mail:
[email protected]
[email protected]
[email protected]
States Covered
States Covered
States Covered
AL, AR, CT, DC, DE, FL, GA,
AB, AK, AZ, BC, CA, CO, HI, IA, IL, IN, KY, MB, MI, MN,
LA, MA, MD, ME, MS, NC, NH, ID, KS, MT, NM, NV, OK, OR, MO, ND, NE, OH, IB, SD, WI
NL, NJ, NY, PA, PR, QC, RI, SC, SK, TX, UT, WA, WY
TN, VA, VT, WV
Packer-buyer must complete Lines No. 1 through 12 and sign and complete Line No. 13.
The Packer must complete Line 14 through 20.
Line
No.
1
2a
through
2e

Subject

Instruction

Name of Applicant to
be Registered
Mailing Address

Enter the name of the individual to be registered.

Form PSD 1100

Enter your mailing address, including street, city, county, state, and
zip+4. This is the address where all correspondence from the Packers
and Stockyards Division should be sent.

Expires 02/28/2021

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Line
No.
3a
through
3e
4
5
6
7
8
9

10
11

12

12a
through
12c
13a
through
13c
14a
through
14c
15
16
17
18
19
20

Subject

Instruction

Operating Address
(if different from

Enter the operating address and/or physical location. Enter street, city,
county, state, and zip+4. This is the address where you conduct your
business services.
Enter the phone number where you can be reached.
Enter your cellphone number.
Enter your fax number.
Enter your e-mail address.
Check the appropriate box to indicate each class of livestock you will
be purchasing for slaughter.

Phone
Cell
Fax
E-Mail Address
Livestock to be
Purchased
for Slaughter
Names and locations of
posted stockyards,
feedlots, or websites…
If you operate a buying
station…
If previously
registered, list
registered name and
address.
Do you own an interest
in other ….
Name, Location,
Percentage of Control
Signature of Applicant,
Print Name, and Date

Enter the name and address, including city and state, of each of the
posted stockyards, feedlots, or web sites where you will purchase
livestock for slaughter.
Enter the name and address, including city, state, and zip+4 where you
operate a buying station.
If you were previously registered with the Packers and Stockyards
Division list each of the name(s) under which you were previously
registered, and the address(es) of the prior business(s).
If you currently operate as, or own any interest in, any dealer
organization(s), market agency(s), stockyard company(s), or packing
company(s), check “Yes” and provide details in the next section,
otherwise, check “No.”
Enter the name(s), location, including city, state, and zip+4, and the
percentage of control or ownership that you maintain in any of the
businesses.
The applicant must sign the application and print the name of the
person signing. Enter the date the form was signed.

THIS SECTION IS TO BE COMPLETED BY THE PACKER-EMPLOYER.
Signature of Employer, An authorized officer of the packer-employer must sign the form, print
Print Officer’s name,
their name, and enter the date the form was signed.
Date
Official title
Enter the official title of the officer signing the application.
Name of Firm
Enter the full name of the employing packer firm.
Address
Enter the address, including city, state and zip+4 of the packer firm.
Telephone
Enter the telephone number of the packer firm.
Email Address
Enter the email address of the packer firm.
Website Address, if
Enter the website address of the packer firm, if applicable.
applicable

Form PSD 1100

Expires 02/28/2021

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