U.S. DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE LIVESTOCK AND POULTRY PROGRAM REGISTRATION OF SHELL EGG HANDLER RETURN THIS REPORT TO: Email: ses@usda.gov Livestock and Poultry Program, AMS U.S. Department of Agriculture 1400 Independence Ave., SW; MAIL STOP 0258 Washington D.C. 20250-0258 No shell egg handler (except a producer - packer with a flock of 3,000 hens or less) who grades and packs eggs for the ultimate consumer may start operations until a registration form has been properly completed and submitted (7 CFR 57.690).

Instructions: Complete and return the original copy to the address shown in the upper middle section. Keep one copy for your records (optional). If more space is needed, use the reverse of the form. Please print or type. FOR USDA USE ONLY

HANDLER NAME: REGISTRATION NUMBER DATE OF REGISTRATION

EMAIL: STATE COUNTY HANDLER

HANDLER NAME: EMAIL: PHONE NUMBER:
DATE OF REGISTRATION_HANDLER

PHONE NUMBER:

State digit 1
State digit 2
County digit 2
country digit 3
country digit 4
Handler digit 1
Handler digit 2
Handler digit 3
Handler digit 4
Email
Phone Number

STREET ADDRESS: SIGNATURE AND TITLE OF USDA OFFICIAL:

USDA Signature
STREET ADDRESS:

CITY, STATE, ZIP CODE: REMARKS:

Title OF USDA OFFICIAL:_Row_1
CITY, STATE, ZIP CODE:

COUNTY IN WHICH BUSINESS IS LOCATED:

REMARKS:
COUNTY IN WHICH BUSINESS IS LOCATED:

PLEASE LIST BELOW IF MAILING ADDRESS DIFFERS FROM STREET ADDRESS:

MAILING ADDRESS:

CITY, STATE, ZIP CODE:

Mailing address CITY, STATE, ZIP CODE:

NATURE OF BUSINESS: (Check as appropriate) PRODUCER/PACKER with more than 3,000 birds [F2] [F8] GRADING STATION

PRODUCER/PACKER with more than 3,000 birds
HATCHERY
COOKED EGG
GRADING STATION
INEDIBLE COLLECTION/PROCESSING
EXEMPT BREAKER

OTHER (Specify) ____________________

OTHER (Specify
OTHER (Specify)__________________________________________________________________________________

Do you pack shell eggs in consumer size containers? ____________________ Do you sell eggs directly to consumers on retail egg routes? ____________________

YES
NO
YES

Do you sell eggs in consumer size containers to retailers or brokers who in turn sell them to retail distributors? ____________________

NO
YES
NO

Do you sell eggs directly to institutional type users (i.e., restaurants, schools, hospitals, etc.)? ____________________

YES
NO

CERTIFICATION OF INDUSTRY PERSONNEL PREPARING REPORT

DATE: TITLE: TYPED OR PRINTED NAME: SIGNATURE:

DATE:
TITLE:
TYPED OR PRINTED NAME:
Signature

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 0581-0113. The time required to complete this information collection is estimated to average 20 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.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual's income is derived from any public assistance program. (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's Target Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider, employer, and lender.

LP-155 (06/2023) Supersedes LPS-155

EXP. DATE: 06/30/2026