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
No

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:
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

MI-1CIS 4-2022