GMIS Application for Meat Inspection Georgia Department of Agriculture - Meat Inspection Divisionhttps://agr.georgia.gov/meat-inspection Office: 404-656-3673 PRIOR ACTION REQUIRED GDA is required by law to verify citizenship/immigration status for the public benefits we issue. These public benefits include licenses, certifications, registrations, and state grants. The full law is O.C.G.A. § 50-36. You will need to provide documentation of your status before you begin this application. You will need to upload an acceptable form of identification and obtain the S&V affidavit from our website at https://agr.georgia.gov/secure-verifiable-documents and have it completed prior to filling out the application so that it can be uploaded later in the process. To: All Interested PartiesFrom: Ms. Andrea Smith: DirectorPlease 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:Georgia Department of Agriculture, HR Department19 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).ORUSDA, 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/Filing Complaints - USDA: https://www.ascr.usda.gov/filing-program-discrimination-complaint-usda-customerDirections for Completion of Application for Inspection FormPlease complete all sections. If a section is not applicable, enter “N/A” or “none”. Establishment Information Name of Establishment Physical Address of Establishment Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Billing Address of Establishment: Same as above Billing Address of Establishment Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Phone Number of Establishment Email address Secondary email address (if applicable) Has the applicant (person, firm or corporation) been convicted in any Federal or State court of any felony? Yes No List each conviction Has the applicant (person, firm or corporation) been convicted in any Federal or 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. Yes No Include the nature of the crime, the date of conviction and the court in which convicted Applicant Information Type of Application New Change of ownership Change of location Other Specify Type of License Required Click the question mark (?) for explanation of license types. Meat (direct sale to consumer - requires State inspection)? Voluntary? Custom Exempt? Poultry Exempt? Retail? Month and Year when establishment will be ready to operate under inspection Form of Organization Individual Cooperative association Corporation Other Specify Name of Corporation State - None -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Date Incorporated Name of Applicant First Last Email Address Mailing Address Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Billing Address of Applicant: Same as above Billing Address of Applicant Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Federal Employer Identification No. (assigned by IRS) Area Code and Telephone Number Establishment Operation Animals to be Slaughtered Cattle Calves Sheep Goats Swine? Feral swine Other Specify Check all that apply (for custom exempt and inspected establishments only) Animals to be slaughtered under voluntary services Bison Buffalo Antelope Elk Water buffalo Quail Ratites (emus and ostriches) Prepared or Processed Activities (Meat/Custom Exempt, Poultry Exempt) Meat (State or voluntary inspection) Check all that apply Breaking/cutting? Boning? Mechanical deboning? Curing? Formulation? Cooking/smoking? Drying? Fabrication? Convenience items? Slicing? Fats/oils? Other Specify Custom Exempt Check all that apply Breaking/cutting? Boning? Mechanical deboning? Curing? Formulation? Cooking/smoking? Canning? Drying? Fabrication? Convenience items? Slicing? Fats/oils? Other Specify Poultry Exempt Check all that apply Chicken Turkeys Ducks Guineas Ratites Squabs Processing whole birds Processing parts Business Structure/Ownership Enter all persons responsibly connected with the establishment. Include all owners, officers, or directors. Include holders or owners of 10 percent 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 percent 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 Person Information Name First Middle Last Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Title Indicate if partner or manager Holder of 10% or more of voting stock (if a Corporation) Yes No N/A Has this person been convicted in any Federal or State court of any felony? Yes No List each conviction Has this person been convicted in any Federal or State court of more than one violation of any law, other than a felony, based on the acquiring, handling, or the distribution of wholesale, mislabeled, or deceptively packaged food or of fraud in connection with transactions in food. Yes No Include the nature of the crime, the date of conviction and the court in which convicted Would you like to add another person? Yes No Person 2 Information Name First Middle Last Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Title Indicate if partner or manager Holder of 10% or more of voting stock (if a Corporation) Yes No N/A Has this person been convicted in any Federal or State court of any felony? Yes No List each conviction Has this person been convicted in any Federal or State court of more than one violation of any law, other than a felony, based on the acquiring, handling, or the distribution of wholesale, mislabeled, or deceptively packaged food or of fraud in connection with transactions in food. Yes No Include the nature of the crime, the date of conviction and the court in which convicted Would you like to add another person? Yes No Person 3 Information Name First Middle Last Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Title Indicate if partner or manager Holder of 10% or more of voting stock (if a Corporation) Yes No N/A Has this person been convicted in any Federal or State court of any felony? Yes No List each conviction Has this person been convicted in any Federal or State court of more than one violation of any law, other than a felony, based on the acquiring, handling, or the distribution of wholesale, mislabeled, or deceptively packaged food or of fraud in connection with transactions in food. Yes No Include the nature of the crime, the date of conviction and the court in which convicted Documents Required Upload a copy of your S&V below: One file only.256 MB limit.Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. Upload a copy of your Driver's License below: One file only.256 MB limit.Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. Agreement and Certification 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 Establishment 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. Signature Sign above Date Title CAPTCHA
Georgia Department of Agriculture - Meat Inspection Divisionhttps://agr.georgia.gov/meat-inspection Office: 404-656-3673 PRIOR ACTION REQUIRED GDA is required by law to verify citizenship/immigration status for the public benefits we issue. These public benefits include licenses, certifications, registrations, and state grants. The full law is O.C.G.A. § 50-36. You will need to provide documentation of your status before you begin this application. You will need to upload an acceptable form of identification and obtain the S&V affidavit from our website at https://agr.georgia.gov/secure-verifiable-documents and have it completed prior to filling out the application so that it can be uploaded later in the process. To: All Interested PartiesFrom: Ms. Andrea Smith: DirectorPlease 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:Georgia Department of Agriculture, HR Department19 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).ORUSDA, 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/Filing Complaints - USDA: https://www.ascr.usda.gov/filing-program-discrimination-complaint-usda-customerDirections for Completion of Application for Inspection FormPlease complete all sections. If a section is not applicable, enter “N/A” or “none”. Establishment Information Name of Establishment Physical Address of Establishment Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Billing Address of Establishment: Same as above Billing Address of Establishment Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Phone Number of Establishment Email address Secondary email address (if applicable) Has the applicant (person, firm or corporation) been convicted in any Federal or State court of any felony? Yes No List each conviction Has the applicant (person, firm or corporation) been convicted in any Federal or 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. Yes No Include the nature of the crime, the date of conviction and the court in which convicted Applicant Information Type of Application New Change of ownership Change of location Other Specify Type of License Required Click the question mark (?) for explanation of license types. Meat (direct sale to consumer - requires State inspection)? Voluntary? Custom Exempt? Poultry Exempt? Retail? Month and Year when establishment will be ready to operate under inspection Form of Organization Individual Cooperative association Corporation Other Specify Name of Corporation State - None -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Date Incorporated Name of Applicant First Last Email Address Mailing Address Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Billing Address of Applicant: Same as above Billing Address of Applicant Address Address 2 City/Town State/Province - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Federal Employer Identification No. (assigned by IRS) Area Code and Telephone Number Establishment Operation Animals to be Slaughtered Cattle Calves Sheep Goats Swine? Feral swine Other Specify Check all that apply (for custom exempt and inspected establishments only) Animals to be slaughtered under voluntary services Bison Buffalo Antelope Elk Water buffalo Quail Ratites (emus and ostriches) Prepared or Processed Activities (Meat/Custom Exempt, Poultry Exempt) Meat (State or voluntary inspection) Check all that apply Breaking/cutting? Boning? Mechanical deboning? Curing? Formulation? Cooking/smoking? Drying? Fabrication? Convenience items? Slicing? Fats/oils? Other Specify Custom Exempt Check all that apply Breaking/cutting? Boning? Mechanical deboning? Curing? Formulation? Cooking/smoking? Canning? Drying? Fabrication? Convenience items? Slicing? Fats/oils? Other Specify Poultry Exempt Check all that apply Chicken Turkeys Ducks Guineas Ratites Squabs Processing whole birds Processing parts Business Structure/Ownership Enter all persons responsibly connected with the establishment. Include all owners, officers, or directors. Include holders or owners of 10 percent 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 percent 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 Person Information Name First Middle Last Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Title Indicate if partner or manager Holder of 10% or more of voting stock (if a Corporation) Yes No N/A Has this person been convicted in any Federal or State court of any felony? Yes No List each conviction Has this person been convicted in any Federal or State court of more than one violation of any law, other than a felony, based on the acquiring, handling, or the distribution of wholesale, mislabeled, or deceptively packaged food or of fraud in connection with transactions in food. Yes No Include the nature of the crime, the date of conviction and the court in which convicted Would you like to add another person? Yes No Person 2 Information Name First Middle Last Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Title Indicate if partner or manager Holder of 10% or more of voting stock (if a Corporation) Yes No N/A Has this person been convicted in any Federal or State court of any felony? Yes No List each conviction Has this person been convicted in any Federal or State court of more than one violation of any law, other than a felony, based on the acquiring, handling, or the distribution of wholesale, mislabeled, or deceptively packaged food or of fraud in connection with transactions in food. Yes No Include the nature of the crime, the date of conviction and the court in which convicted Would you like to add another person? Yes No Person 3 Information Name First Middle Last Address Address Address 2 City/Town State/Province - Select -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNova ScotiaNorthwest TerritoriesNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon ZIP/Postal Code Title Indicate if partner or manager Holder of 10% or more of voting stock (if a Corporation) Yes No N/A Has this person been convicted in any Federal or State court of any felony? Yes No List each conviction Has this person been convicted in any Federal or State court of more than one violation of any law, other than a felony, based on the acquiring, handling, or the distribution of wholesale, mislabeled, or deceptively packaged food or of fraud in connection with transactions in food. Yes No Include the nature of the crime, the date of conviction and the court in which convicted Documents Required Upload a copy of your S&V below: One file only.256 MB limit.Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. Upload a copy of your Driver's License below: One file only.256 MB limit.Allowed types: gif, jpg, jpeg, png, bmp, eps, tif, pict, psd, txt, rtf, html, odf, pdf, doc, docx, ppt, pptx, xls, xlsx, xml, avi, mov, mp3, mp4, ogg, wav, bz2, dmg, gz, jar, rar, sit, svg, tar, zip. Agreement and Certification 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 Establishment 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. Signature Sign above Date Title CAPTCHA
