===== PAGE 1 ===== # 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. 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 ===== PAGE 2 ===== # MONTANA DEPARTMENT OF LIVESTOCK USE ONLY Cooperative Interstate Shipment Program Application checklist – completed by MPI staff

Regulatory Compliance
Last FSA Completed Date:		Completed By:
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
Source Material	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
List of Products for CIS
Administrative
Has the establishment ever been under USDA inspection?		Yes	No
Has the establishment been under a state Grant of Inspection for 90 days? If No, date the establishment will reach 90 days of under state inspection:
Authorization		I acknowledge establishment is in good standing with Montana MPI and is recommended for selection. Bureau Chief Signature Print Name of Signer:
Bureau Chief’s Recommendation for Selection
		CIS Assigned Establishment Number:

MI-1CIS 4-2022