Application for State Meat and Poultry Inspection AHS-09-54

No grant for State Meat or Poultry Inspection may be issued unless this completed application has been received

Complete all sections. If a section is not applicable, enter “N/A” or “None”.
1. DATE*

MonthDayYear
Date
2. TYPE OF APPLICATION*

NewChange of LocationChange of ownerOther
3. TYPE OF INSPECTION REQUIRED*

MeatPoultryVoluntary ExoticOther
4. FORM OF ORGANIZATION*

IndividualCorporationCooperative AssociationPartnershipOther
5. IF CORPORATION: NAME OF STATE WHERE INCORPORATED

Street Address

Street Address Line 2

CityState

Zip Code
6. DATE INCORPORATED (Month and Year)

MonthDayYear
Date
7. NAME OF APPLICANT, COMPANY NAME, AND MAILING ADDRESS*

First NameLast Name
Company Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
8. Phone Number*
Please enter a valid phone number.
9. LOCATION OF PLANT AND PHYSICAL ADDRESS

Street Address

Street Address Line 2

CityState

Zip Code
10. Email*

Confirmation Emailexample@example.com
11. Phone Number
Please enter a valid phone number.
12. OTHER NAMES (if any) UNDER WHICH BUSINESS WILL BE CONDUCTED
13. OFFICIAL NUMBER ASSIGNED/RESERVED (Completed by Ofﬁce)
14. INSPECTED

SlaughterProcessing
15. CUSTOM EXEMPT

SlaughterProcessing
16. IS THIS PLANT PRESENTLY UNDER STATE INSPECTION?

YesNo
17. DAYS PER YEAR PLANT WILL OPERATE
18. HOURS PER WEEK PLANT WILL OPERATE
19. HOURS PER DAY PLANT WILL OPERATE
20. MONTH AND YEAR WHEN PLANT WILL BE READY TO OPERATE UNDER INSPECTION PROGRAM DATE

MonthDayYear
Date

21. ESTIMATED WEEKLY NUMBER OF ANIMALS TO BE SLAUGHTERED WHEN INPECTION IS INAUGURATED

	Cattle	Calves	Sheep	Goats	Swine	Exotic
Slaughter Only

	Young Chickens	Mature Chickens	Turkeys	Geese	Ducks	Guineas
Slaughter Only

22. ESTIMATED WEEKLY VOLUME TO BE PREPARED OR PROCESSED WHEN INSPECTION IS INAUGURATED. What types of products will be processed?

Voluntary Exotic MeatVoluntary Exotic PoultyMeatPoultry
Processing

a. Fully Cooked - Not Shelf Stableb. Heat Treated Not Fully Cooked - Not Shelf Stablec. Heat Treated - Shelf Stabled. Not Heat Treated - Shelf Stablee. Product with Secondary Inhibitors - Not Shelf Stablef. Raw - Intact Productsg. Raw - Non Intact Productsh. Thermally Processed Commercially SterileOther
This is an equal opportunity program. If you believe you have been discriminated against because of Race, Color, National Origin, sex, age, or disability, contact the LDAF, 5825 Florida Blvd., Suite 4003, Baton Rouge, LA 70806; phone (225) 922-1358/State Relay Service (800) 947-5277; or USDA’s Office of the Assistant Secretary for Civil Rights, 1400 Independence Ave. SW, Washington, DC 20250-9410.

No grant for State Meat or Poultry Inspection may be issued unless this completed application has been received