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

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.
1. DATE OF APPLICATION

MonthDayYear
2. TYPE OF APPLICATION

OTHER (Specify)
3. TYPE OF INSPECTION REQUIRED
4. FORM OF ORGANIZATION

OTHER (Specify)
5. IF CORPORATION: NAME OF STATE WHERE INCORPORATED
6. DATE INCORPORATED (Month and Year)

MonthYear
7. NAME OF APPLICANT AND COMPANY NAME
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
8. APPLICANT'S AREA CODE AND TELEPHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
9. LOCATION OF PLANT AND PHYSICAL ADDRESS (Include ZIP Code)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
10. E-MAIL ADDRESS
example@example.com
11. PLANT'S AREA CODE ADN TELEPHONE NUMBER
Please enter a valid phone number.Format: (000) 000-0000.
12. OTHER NAMES (if any) UNDER WHICH BUSINESS WILL BE CONDUCTED
13. OFFICIAL NUMBER ASSIGNED/RESERVED (COMPLETED BY OFFICE)
14. INSPECTED
15. CUSTOM EXEMPT
16. IS THIS PLANT PRESENTLY UNDER STATE INSPECTION?
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

MonthYear

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

Rows	WEEKLY NUMBER TO BE SLAUGHTERED
CATTLE
CALVES
SHEEP
GOATS
SWINE
EQUINES
YOUNG CHICKENS
MATURE CHICKENS
TURKEYS
GEESE
DUCKS
GUINEAS

22. ESTIMATED WEEKLY VOLUME TO BE PREPARED OR PROCESSED WHEN INSPECTION IS INAUGURATED.

Rows	Type of Product	Estimated Weekly Volume to be Prepared or Processed
a. Fully Cooked - Not Shelf Stable
b. Heat Treated Not Fully Cooked - Not Shelf Stable
c. Heat Treated - Not Shelf Stable
d. Not Heat Treated - Shelf Stable
e. Product with Secondary Inhibitors - Not Shelf Stable
f. Raw - Intact Products
g. Raw - Non-Intact Products
h. Thermally Processed Commercially Sterile
Other (Specify below)

OTHER (Please specify)
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.

APPLICATION FOR STATE MEAT AND POULTRY INSPECTION

Responsible Person #1

Responsible Person #2

Responsible Person #3

Responsible Person #4

Responsible Person #5