To:
From:
OR
MEAT if the species is cattle, swine, sheep or goats
VOLUNTARY if reimbursable inspection of species non-amenable to the Meat Act are intended.
POULTRY (Poultry Exempt Only)
NEW -for previously unlicensed facility
CHANGE OF OWNER - licensed facility when any change in ownership is made regarding
10 percent or more of the business
CHANGE OF LOCATION - licensed facility when any change in physical or mailing address
is made ownership
OTHER (Specify) - when any other Updates or corrections need to be made in the official
application
3. Type of License Required: Check applicable block
Filing Complaints USDA: https://www.ascr.usda.gov/filing-program-discrimination-complaint-usda-customer
Directions for Completion of Application for Inspection Form
Please complete all sections. If a section is not applicable, enter “N/A” or “none”. If additional
space is needed for any item, attach a sheet and number the item.
1. Date of Application: Shall be the date on which the form is executed
2. Type of Application: Check applicable box
Please be advised that In accordance with Georgia law, Georgia Department of Agriculture policy;
Federal law and U. S. Department of Agriculture policy (our cooperating partner), this institution is
prohibited from discrimination in its programs and services on the basis of race, color, national origin,
sex, religion, age, or disability. To file a complaint of discrimination, contact:
Equal Employment Opportunity Officer
Ms. Dawnn Johnson, HR Director
Georgia Department of Agriculture
19 Martin Luther King Jr. Drive, Suite 300
Atlanta, GA 30334
(800) 282-5852 (voice)
(404) 656-3673 (voice)
For deaf and hard-of-hearing users, please
call through a Relay service (in Georgia, dial
711).
USDA, Director, Office of Civil Rights 1400
Independence Avenue, S. W.
Washington, DC 20250-9410
(800) 795-3272 (voice)
(202) 720-6382 (TDD)
The following Web addresses can be accessed for more information :
Georgia Department of Agriculture
http://agr.georgia.gov/
Tyler Harper
Commissioner
Meat Inspection
Room 122 Capitol Square
19 Martin Luther King, Jr. Dr., SW
Atlanta, Georgia 30334-4201
Office: 404-656-3673
Facsimile: 404-463-1998
Georgia Department of Agriculture
All Interested Parties
Ms. Andrea Smith: Director
This institution is an equal opportunity employer and service provider
Section 3. Including Blocks 27 through 42 are to be completed by Georgia
Department of Agriculture personnel only.
Submit application.
5. Form of Company Organization: Check applicable block
6. State Where Incorporated: Self-explanatory.
7. Date Incorporated: Self-explanatory- Show month and year.
8. Name and address of Applicant: Show official firm name and address. Enter Federal Employee
identification number assigned by the Internal Revenue Service in the space provided.
9. Area Code and Telephone Number: Self-explanatory.
10. Location of Plant and Mailing Address if Different From Item 8: If the mailing address of Item 8 is
a P. O. Box number or the physical address is not at the facility, then show location of the plant by street,
number, miles from town or highway, etc.
11. Area Code and Telephone Number: Show plant’s actual telephone number(s).
12. Name and Establishment Number(s) of Other Establishments Located in the Same Facility: Name
of person(s) or firm name(s) and establishment number(s) which prepare products within the same
facilities of the applicant identified in Item 8.
13. Other Names Under Which Business Will Be Conducted: This refers to subsidiaries doing business
under a different name than the applicant requesting inspection.
14. Day/Year Plant Will Operate: Includes both exempt and Inspected processes.
15. Hours/Week Plant Will Operate: Includes both exempt and Inspected processes.
16. Hours/Day Plant Will Operate: Includes both exempt and Inspected processes.
17. Month and Year Plant Will Be Ready to Operate Under Inspection Program: A facility could start
with non-exempt activities and intend to engage in inspected activities later. Self- explanatory. There can
be overlapping exempt and non-exempt reporting, e.g., an applicant may have in Section 16, 8 hours
exempt and 8 hours non-exempt. This does not necessary mean the plant is scheduled to work 16 hours.
18. Animals Slaughtered: Check applicable block(s). (For CE and Inspected Establishments Only)
(*Do not include hunter killed swine in the section)
19. Fresh or processed product to be produced: Check applicable block(s). (For CE and Inspected
Establishments Only) (*Include hunter killed swine in this section)
20. Prepared or Processed activities: Check applicable block(s) if Meat/Custom Exempt/Poultry
Exempt products are processed.
21. List of Responsible Persons: Shall include person signing the application, owners, officers,
directors, managers, or others in an executive capacity or holding more than 10% of voting stock. Be
sure to show name, title, social security number, date and place of birth, home address and check in the
space provided concerning holding of stock. This must be completed prior to issuance of license.
22. Person(s) Convicted of a Felony: Self-explanatory, if none, write none.
23. Convictions Against the Applicants: Self-explanatory.
24. Person Signing Application: Applicant’s name should be typed or legibly printed.
25. Signature: Applicant needs to sign in ink.
26. Title: Title of applicant whose name appears in Blocks 24 and 25
d. Islamic (IS)
e. Buddhist (BU)
f. Confucianist (CO)
An applicant can show one or any combination of the six, if needed.
4. Exempted Activities: There are several possible entries:
This institution is an equal opportunity employer and service provider
CUSTOM
CHANGE OF OWNER
POULTRY
RETAIL
OTHER (Specify)
INDIVIDUAL
EXEMPT NON-EXEMPT EXEMPT NON-EXEMPT EXEMPT EXEMPT
CATTLE
CALVES
SWINE
BEEF
VEAL
PORK
POULTRY
EXEMPT
POULTRY (Poultry Exempt
Only)
4. EXEMPT ACTIVITIES
1. DATE OF APPLICATION
NEW
OTHER (Specify)
CHANGE OF LOCATION
3. TYPE OF INSPECTION REQUIRED
MEAT
VOLUNTARY
GEORGIA DEPARTMENT OF AGRICULTURE
APPLICATION FOR LICENSE TO OPERATE
AN ABATTOIR AND/OR MEAT PROCESSING PLANT
INSTRUCTIONS: Completely fill out all parts of the applicant’s section and submit this application to:
Director: Meat Inspection Section
Georgia Department of Agriculture, Room 122
19 Martin Luther King, Jr. Drive, SW
Atlanta, Georgia 30334-4201
For facilities not previously providing such services, you must also attach and submit
three sets of blueprints/drawings of the plant. Complete all sections. If a section is not
applicable, you may enter N/A or NONE. If additional space is needed for any item,
please attach an additional sheet with the information appropriately labeled to the number
of the corresponding item.
SECTION 1: (to be completed by APPLICANT for State Inspection Activities)
IF CORPORATION
5. FORM OF ORGANIZATION:
COOPERATIVE ASSOCIATION
CORPORATION
OTHER (Specify)
6. NAME OF STATE WHERE INCORPORATED
7. DATE INCORPORATED (Month and Year)
10a. LOCATION OF PLANT AND MAILING ADDRESS IF DIFFERENT FROM ITEM 8 (Include Zip Code)
11. AREA CODE TELEPHONE
NUMBER
8. NAME OF APPLICANT (Company Name) AND BILLING ADDRESS (Include Zip Code)
FEDERAL EMPLOYER IDENTIFICATION
NO. (Assigned by IRS)
9. AREA CODE TELEPHONE NUMBER
12. NAME AND ESTABLISHMENT NUMBER OF OTHER ESTABLISHMENTS LOCATED IN
THE SAME FACILITY
13. OTHER NAMES (If any) UNDER WHICH APPLICANT WILL ALSO CONDUCT BUSINESS
14. DAYS PER YEAR PLANT WILL
OPERATE
15. HOURS PER WEEK PLANT
WILL OPERATE
NON-EXEMPT
NON-EXEMPT
18. ANIMALS TO BE SLAUGHTERED
SHEEP
GOATS
OTHER (Specify)
19. FRESH OR PROCESSED PRODUCTS TO BE PRODUCED
20. PREPARED OR PROCESSED ACTIVITIES
CUSTOM
EXEMPT
LAMB OR MUTTON
GOAT MEAT
OTHER (Specify)
TYPE OF
PRODUCT
MEAT
Whole birds
Parts
PRIVACY ACT NOTICE: The Privacy Act of 1974 (5 U.S.C. 552a) requires that certain information be given to you when you are requested to furnish personal information to a Government agency. The required information is provided in
this notice. The Act does not apply, however, to business information about your firm. AUTHORITY FOR REQUESTING INFORMATION: Authority for requesting both personal and business information is contained in the Federal Meat
Inspection Act (21 U.S.C. 601 et seq.). Under this Act, the Secretary of Agriculture is authorized to determine the fitness of applicants for or recipients of inspection service to engage in business requiring inspection. Your disclosure of
personal information to aid in this determination is mandatory. The Act also requires full and complete disclosure of records and information showing the transactions of your business. PURPOSE FOR WHICH THE INFORMATION WILL
BE USED: This information is being requested to establish and record your identity as a responsible official of the business and to determine your fitness to receive a grant of inspection. ROUTINE USES WHICH MAY BE MADE OF THE
INFORMATION: In appropriate situations, a report containing the information you furnish may be referred to other Federal, State, local or foreign agencies charged with law enforcement or the investigation or prosecution of law violations.
EFFECTS OF FAILURE TO FURNISH INFORMATION: Failure to provide requested information may delay or interfere with your receiving inspection service and may result in civil penalties of $100 per day against you or your business,
as prescribed by 15 U.S.C. 50. In addition, persons making false, fictitious, or fraudulent statements or entries are subject to up to $20,000 fine or 5 years imprisonment.
THIS INSTITUTION IS AN EQUAL OPPORTUNITY EMPLOYER AND SERVICE PROVIDER
FERAL SWINE
FERAL SWINE
(For Custom Exempt and Inspected Establishments Only)
(For Custom Exempt and Inspected Establishments Only)
Chicken
Guineas
Ratites
Squabs
Turkey
s
Ducks
Processing:
APPLICATION FOR INSPECTION FORM GAMIS 01-2010 (modified 4/10)
21. List all persons responsibly connected with the applicant. Include all owners, officers, or directors. Include holders or owners of 10 per centum or more of
voting stock, and employees in a managerial or executive capacity in the business. Any change in ownership resulting in an additional party or person(s)
controlling 10 per centum or more of the voting stock must be reported on an updated application for review and approval by the Director of Meat Inspection
or their designee within 30 days. Attach additional sheet listing all required information if needed.
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 of State court of any felony. Enter the name of each person
listed under Item 21 who has been convicted in any Federal of State court of more than one violation of any law, other than a felony, based upon the acquiring,
handling, or distribution of wholesale, 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 that 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”
SECTION 2. (To be completed by OWNER, PARTNER, or AUTHORIZED OFFICER making the Application.)
AGREEMENT AND CERTIFICATION: In compliance with O.C.G.A 26 - 2 - 200, et seq. and O.C.G.A. 4 - 4 - 40, et seq., I (We) hereby make application to the
Georgia Department of Agriculture for an Abattoir and/or Meat Processing Plant License. I (We) expressly agree if inspection is granted under this application, to
conform strictly with all applicable rules and regulations including: the “Georgia Meat Inspection Act” (O.C.G.A. § 26-2-60); the “Federal Meat Inspection Act” (21
U.S.C 601 et seq.); and humane slaughter requirements (OCGA O.C.G.A. § 26-2-110 and the “Humane Methods of Slaughter Act” - 7 U.S.C 19601 et seq.) . I (We)
agree to: cooperate fully with the inspection personnel of the Georgia Department of Agriculture; to adjust slaughter schedules as required; and adequately maintain
sanitation site, facilities and equipment. I (We) understand that the Georgia Department of Agriculture may withdraw or suspend the license for failure to abide by
all rules and regulations or failure to operate as scheduled. I (We) understand that compliance is additionally required with all other applicable
federal, state, and local laws, rules, and ordinances, whether or not administered by the Georgia Department of Agriculture. I (We) understand
the license is not transferable. I (We) understand that any person(s) willfully making false, factitious, or fraudulent statements of entries on this form may be
subject to fines up to $ 20,000, imprisonment for up to five years or both. I (We) agree to all requirements above and certify that all
statements made herein or true to the best of my knowledge.
24. TYPED NAME of PERSON SIGNING APPLICATION
SIGNATURE AND TITLE
25. SIGNATURE
26. TITLE
SECTION 3. TO BE COMPLETED BY GEORGIA DEPARTMENT OF AGRICULTURE PERSONNEL ONLY
ACTION
SIGNATURE /INITIALS
DATE COMPLETE
ACTION- ENTER INTO
SIGNATURE /INITIALS
DATE
COMPLETE
27. APPLICATION DATE RECEIVED
34. ADD to SAMPLING
DATABASE
28. ESTABLISH FILE
35. ADD to SLAUGHTER
DATABASE
29. RESERVE NUMBER
36. ADD to/ UPDATE
ESTABLISHMENT DIRECTORY
30. NOTIFY SUPERVISOR
37. NOTIFY SUPERVISOR –
ARRANGE STAFFING
31. RECEIVE SUPERVISOR’S SURVEY
RECOMMENDATION
38. APPLICATION PROCESSED
32. REVIEW AND APPROVE LABELS
39. LICENSE MAILED
33. ADD to PHIS
40. COMPLETED/
VERIFIED
41. SIGNATURE : DIRECTOR OF MEAT INSPECTION OR PROGRAM MANAGER
42. DATE
The Georgia Department of Agriculture, Meat Inspection Program is an equal opportunity employer and service provider program. If you believe you have been discriminated against because of race, color, national origin,
age, sex, religion or disability, please write or call immediately the GDA EEO Officer, Ms. Cora Potter Keenan, Personnel Director, Georgia Department of Agriculture, 19 Martin Luther King Jr. Drive, Suite 300, Atlanta,
GA 30334 [(800) 282-5852 (voice), (404) 656-3673 (voice ) For deaf and hard-of-hearing users, please call through a Relay service (in Georgia, dial 711) or USDA, Director, Office of Civil Rights, 1400 Independence
Avenue, S. W. Washington, DC 20250-9410 [(800) 795-3272 (voice), (202) 720-6382 (TDD). Public reporting burden for this collection of information is estimated to average 30 minutes per response, including the time
for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
APPLICATION FOR INSPECTION FORM GAMIS 01-2010 (modified 10/10) THIS INSTITUTION IS AN EQUAL OPPORTUNITY EMPLOYER AND SERVICE PROVIDER