INSTRUCTIONS FOR COMPLETION OF MPID Form 1f
Complete all sections. Enter
“
N/A
”
or
“
None
”
if a section is not applicable. If additional space is needed for any item, attach sheet and number the item
.
Submit the application to the State Director. Meat and Poultry Inspection Division, N.C. Department of Agriculture for applicable inspection
requests.
SECTION I.
1.
Date of Application: Put current date application is completed.
2.
Type of Application (check all that apply).
3.
Type of Inspection (check all that apply). Meat Slaughter, Meat Processing, Meat Sl. & Proc., and Poultry Proc. are for establishments where product will bear the mark of
inspection for wholesale. Custom is for products to be stamped not for sale and returned to owner for their own consumption.
4.
Exempted Activities (check all that apply). Retail Activities are for products sold directly to the end consumer. Food & Drug Activities are for non-meat
and poultry items produced within the facility for wholesale. Non-Amenable is for processing of wild game that does not require inspection per the N.C.
Compulsory Meat Inspection Law such as deer and bear.
5.
Form of Organization (check applicable box).
6.
If Corporation, Name of State where Incorporated.
7.
Date Incorporated: Show month and year.
8.
Name of applicant (Company Name) and mailing address (Include ZIP Code).
9.
County.
10.
Area Code and Telephone Number.
11.
Email Address.
12.
Location of plant and mailing address if different from item 8 (Include ZIP Code).
13.
Area code and telephone number.
14.
Name and establishment number of other establishments located in the same facility.
15.
Other names (if any) under which business will be conducted.
16.
Days per year plant will operate. Exempt is for days you will produce product not bearing the mark of inspection and non-exempt is for days you will
produce product required to bear the mark of inspection per N.C. Compulsory Meat Inspection Law and N.C. Poultry Products Inspection Law.
17.
Hours per week plant will operate. Exempt is for hours per week you will produce product not bearing the mark of inspection and non-exempt is for hours
per week you will produce product required to bear the mark of inspection per N.C. Compulsory Meat Inspection Law and N.C. Poultry Products
Inspection Law.
18.
Hours per day plant will operate. Exempt is for hours per day you will produce product not bearing the mark of inspection and non-exempt is for hours
pe
r day you will produce product required to bear the mark of inspection per N.C. Compulsory Meat Inspection Law and N.C. Poultry Products Inspection
Law.
19.
Month and year when plant will be ready to operate under inspection.
SECTION
II.
20.
Animals to be slaughtered when inspection is inaugurated (select all that apply).
21.
Processing activities when inspection is inaugurated (select all that apply).
SECTION Ill.
22.
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.
23.
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".
24.
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”.
PLEASE READ AGREEMENT AND CERTIFICATION STATEMENT
25.
Name of person signing application.
26.
Signature.
27.
Title.
28.
Official number assigned/reserved. Leave blank if a new establishment.
29.
Is the plant presently under state inspection?
BLOCKS 30, 31, AND 32 - TO BE COMPLETED BY NCDA&CS, MPID OFFICE ONLY
