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MONTANA DEPARTMENT OF LIVESTOCK MEAT & POULTRY INSPECTION BUREAU PO BOX 202001 HELENA MT 59620

Cooperative Interstate Shipment (CIS) Program Application

Establishment must already have a license to operate in the State of Montana and a State Grant of Inspection in good standing from the Montana Department of Livestock.

ESTABLISHMENT INFORMATION

Est. Name: Est. Number:

Est. Number:

Est. Name:

Est. Address: Contact Name:

Est. Address:

Contact Name:

Contact Phone No. Email:

Contact Phone No.

Email:

EMPLOYEES: # of Fulltime employees in past 12 mos. ______ # of part time, or volunteers ____

of part time, or volunteers

EMPLOYEES: # of Fulltime employees in past 12 mos

Have you ever had more than 25 employees? Yes No

Yes

Species being further processed under CIS: Meat Poultry

Meat

Poultry

“Active” HACCP PLAN CATEGORIES FOR COOPERATIVE INTERSTATE SHIPMENT PROGRAM

List species:

Slaughter

List products:

Raw Intact

List products:

Raw Non Intact

List products:

Thermally Processed – commercial sterile

List products:

Not heat treated – shelf stable

List products:

Heat treated – shelf stable

List products:

Fully cooked – not shelf stable

Heat treated – not fully cooked, not

List products:

Secondary Inhibitors – not shelf stable

Authorization – Application must be signed by person named on State Grant of Inspection

Print Applicant Name: Applicant Signature: Date:

Date:

Print Applicant Name:

SIGN

NONDISCRIMINATION STATEMENT: This is an equal opportunity program. If you believe you have been discriminated against because of race, color, national origin, age, sex, or disability immediately contact USDA, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington, D.C. 20250-9410. Call Toll-Free: (866) 632-9992, Federal relay: (800) 877-8339, Spanish relay: (800) 845-6136, Fax: (202) 690-7442, or Email: Program.intake@usda.gov

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MONTANA DEPARTMENT OF LIVESTOCK USE ONLY Cooperative Interstate Shipment Program Application checklist – completed by MPI staff

Regulatory Compliance

Last FSA Completed Date:

Completed By:

9 CFR 416: SPS and SSOP

9 CFR 417: HACCP

9 CFR 418: Recall Plan

Food Defense (Voluntary)

Verified: 9 CFR 416: SPS and SSOP 9 CFR 418: Recall Plan 9 CFR 332.13: Written plant to address separation by time & space Water and sewage approval Labels for Cooperative Interstate Shipment (CIS) in compliance

9 CFR 332.13: Written plant to address separation by time & space

Water and sewage approval

Source Material Verified source materials are from which USDA establishment:

Labels for Cooperative Interstate Shipment (CIS) in compliance

Verified source materials are from which USDA establishment:

Slaughter Last Review Date for Humane Handling/Good Commercial Practices review: Controls for SRM Controls for Listeria Monocytogenes

Last Review Date for Humane Handling/Good Commercial Practices review:

Controls for SRM Controls for Listeria Monocytogenes

Handling/Good

List of Products for CIS

Administrative

List Products

List Products (continued)

Has the establishment ever been under USDA inspection? Yes No

Yes

Date to meet 90 days under Inspection

Authorization I acknowledge establishment is in good standing with Montana MPI and is recommended for selection. Bureau Chief Signature Print Name of Signer:

Date:

Bureau Chief Signature

Print Name of Signer:

Bureau Chief’s Recommendation for Selection

CIS Assigned Establishment Number:

MI-1CIS 4-2022