SECTION I

 

1.      DATE OF APPLICATION

 

 

2. TYPE OF APPLICATION

 

NEW CHANGE OF CHANGE OF OWNER LOCATION

 

OTHER (specify)

3. TYPE OF INSPECTION REQUIRED

MEAT SLAUGHTER POULTRY PROC. MEAT PROCESSING CUSTOM

MEAT SL. & PROC.

4. EXEMPTED ACTIVITIES

 

RETAIL ACTIVITIES

 

FOOD & DRUG ACTIVITIES

5. FORM OF ORGANIZATION

 

INDIVIDUAL COOPERATIVE ASSOCIATION PARTNERSHIP CORPORATION OTHER (specify)

6. IF CORPORATION; NAME OF STATE WHERE INCORPORATED

7. DATE OF INCORPORATION (Month and Year)

 

 
8. NAME OF APPLICANT (Company Name) AND MAILING ADDRESS (Include ZIP Code)

9. COUNTY

10. AREA CODE AND TELEPHONE NUMBER

10a. EMAIL ADDRESS

 

 
11. LOCATION OF PLANT AND MAILING ADDRESS IF DIFFERENT FROM ITEM 8 (Include ZIP Code)

12. AREA CODE AND TELEPHONE NUMBER

13. NAME AND ESTABLISHMENT NUMBER OF OTHER ESTABLISHMENTS LOCATED IN THE SAME FACILITY

14. OTHER NAMES (If any) UNDER WHICH BUSINESS WILL BE CONDUCTED

15. DAYS PER YEAR PLANT WILL OPERATE

16. HOURS PER WEEK PLANT WILL OPERATE

17. HOURS PER DAY PLANT WILL OPERATE

18. MONTH AND YEAR WHEN PLANT WILL BE READY TO OPERATE UNDER INSPECTION

EXEMPT

NON-EXEMPT

EXEMPT

NON-EXEMPT

EXEMPT

NON-EXEMPT

EXEMPT

NON-EXEMPT

 

 

 

 

 

 

 

 

SECTION II

 

SLAUGHTER

19. ANIMALS TO BE SLAUGHTERED WHEN INSPECTION IS INAUGURATED

 

CATTLE

 

CALVES

 

SHEEP

 

GOATS

 

SWINE

 

RATITES

 

OTHER (specify)

PROCESSING

20. PROCESSING ACTIVITIES WHEN INSPECTION IS INAUGURATED

TYPE OF PRODUCT

 

MEAT POULTRY BOTH

 

a.       BREAKING/CUTTING (carcasses, primal cuts, whole poultry, poultry parts, etc.) h.

b.       BONING (manual boning meat/poultry) i.

c.       MECHANICAL DEBONING (mechanical deboning meat/poultry) j.

d.       FABRICATING (roast, steaks, chops, ground beef, hamburger, etc.) k.

e.       CURING (pork cuts, beef cuts, turkey, ham, etc.) l.

f.        FORMULATING (fresh/cured sausages, loaves, poultry rolls, pattie mix, m.

g.       COOKING/SMOKING (pork cuts, beef cuts, sausage, loaves, etc.)

 

CANNING (shelf stable, perishable, cans, pouches, glass) DRYING (pork cuts, beef cuts, sausage, dehydrated products) CONVENIENCE ITEMS (entrees, dinners, pies, pizzas, etc.) SLICING (bacon, luncheon meats, sausage, etc.)

FATS/OILS (lard, tallow, shortening, margarine, etc.)

OTHER (specify)


 

SECTION III

 

21. List all persons responsibly connected with the applicant. Include all owners, partners, officers, directors, holders or owners of 10 per centum or more of voting stock, and employees in a managerial or executive capacity in the business. Notify the State Director of any changes in the listing given.

 

NAME

SOCIAL SECURITY NUMBER

DATE OF BIRTH

PLACE OF BIRTH

(City and State)

PRESENT HOME ADDRESS

(Street and Number, City, State, Zip Code)

HOLDER OF 10% OR MORE VOTING STOCK (If Corp.)

TITLE (Indicate if partner, manager)

 

 

 

 

 

YES (X)

NO (X)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22.  Enter the name of each person listed under Item 21 who has been convicted in any Federal or State court of any felony. Enter the name of each person listed under Item 21 who has been convicted in any Federal or State court of more than one violation of any law, other than felony, based upon the acquiring, handling, or distributing of unwholesome, mislabeled, or deceptively packaged food or upon fraud in connection with transactions in food. Include the nature of the crime, the date of conviction and the court in which convicted. If none write "None".

 

 

 

 

 

 

23.  List each conviction against the applicant (person, firm or corporation) in any Federal or State court of any felony. List each conviction against the applicant (person, firm or corporation) in any Federal or State court of more than one violation of any law, other than a felony, based upon the acquiring, handling, or distributing of unwholesome,

mislabeled, or deceptively packaged food or upon fraud in connection with transactions in food. Include the nature of the crime, the date of conviction and the court in which convicted. If none write "None."

 

 

 

 

 

 

AGREEMENT AND CERTIFICATION: If inspection is granted under this application, I (we) expressly agree to conform strictly to the N.C. Compulsory Meat Inspection Law (Articles 49B, 49C, and 49H of the General Statues of North Carolina) the N.C. Poultry Products Inspection Law (Article 49D, Chapter 106 of the General Statues of North Carolina), or both. I CERTIFY that all statements made herein are true to the best of my knowledge and belief.

 

This is an Equal Opportunity Program. If you believe you have been discriminated against because of race, color, religion, sex, national origin, age, or handicap, write to: State Director, NCDA&CS-MPID, Agriculture Building, 1001 Mail Service Center, Raleigh, NC 27699-1001.

 

24. TYPED NAME OF PERSON SIGNING APPLICATION

SIGNATURE AND TITLE OF OWNER, PARTNER, OR AUTHORIZED OFFICER MAKING THIS APPLICATION

25. SIGNATURE

26. TITLE

27. OFFICIAL NUMBER ASSIGNED/RESERVED

 

 

EST

28. IS THIS PLANT PRESENTLY UNDER STATE INSPECTION?

YES NO

TO BE COMPLETED BY NCDA

 

29. DATE RECEIVED

30. DATE REVIEWED

31. SIGNATURE OF STATE DIRECTOR