AHS-09-54 APPLICATION FOR STATE MEAT AND POULTRY INSPECTION ADA Logo
  • APPLICATION FOR STATE MEAT AND POULTRY INSPECTION

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

    INSTRUCTIONS: Submit this application to the Director, Meat and Poultry Inspection, Louisiana Department of Agriculture & Forestry, 5825 Florida Blvd., Suite 4003, Baton Rouge, LA 70806. Complete all sections. If a section is not applicable, enter “N/A” or “None”. If additional space is needed for any item, attach sheet and number the item.

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  • 13. OFFICIAL NUMBER ASSIGNED/RESERVED (COMPLETED BY OFFICE)

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  • 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.

  • 23. List all persons responsibly connected with the applicant. Include all partners, officers, directors, holders or owners of 10 per centum or more of voting stock, and employees in a managerial or executive capacity in the business. Notify the Area Supervisor of any changes in the listing given.

  • Responsible Person #1

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  • Responsible Person #2

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  • Responsible Person #3

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  • Responsible Person #4

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  • Responsible Person #5

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  • AGREEMENT AND CERTIFICATION: If inspection is granted under the application, I (we) expressly agree to conform strictly to the State Meat and Poultry Inspection law (Originally Chapter 14, Title 40 of LA R.S. 40:2271 et.seq. redesignated Chapter 27, Title 3 R.S. 3:4201 to 3:4233) and Regulations under Louisiana Administrative code Title 7, Part XXXIII, Chapter 169, 16901 to 169331 or both. I certify that all statements made here in are true to the best of my knowledge and belief.

    WARNING: Persons willfully making false, fictitious, or fraudulent statement or entries are subject to $5,000 fine or imprisoned not more than five years or both.

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