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. Address: Contact Name:

Contact Phone No. Email:

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

Have you ever had more than 25 employees? Yes No

Species being further processed under CIS: Meat Poultry

“Active” HACCP PLAN CATEGORIES FOR COOPERATIVE INTERSTATE SHIPMENT PROGRAM

Slaughter List species:

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 List products:

Heat treated – not fully cooked, not shelf stable List products:

Secondary Inhibitors – not shelf stable List products:

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

Print Applicant Name: Applicant Signature: Date:

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