Permission For Publication
Interstate Milk Shipper Listing

Shipper's Name: __________________________________________________________

Address: ________________________________________________________________

You are hereby advised that on (date[s]) _____________________ a State Rating or HACCP Listing Audit was conducted with the following results:

Producer Supply (BTU) ______________________ Transfer Station _____________________

Receiving Station: ___________________________ Pasteurization Plant: __________________

Condensed or Dry Milk Plant: ____________________________________________________

Enforcement Rating (For all ratings and for attached farm supplies of HACCP listings): __________

The results will be transmitted to the U.S. Food and Drug Administration. They will publish the information in the semi-annual "IMS List-Sanitation Compliance and Enforcement Ratings of Interstate Milk Shippers". The official Rating or HACCP Listing is valid for a period not to exceed two years from the earliest rating/listing date, subject to the rules of the National Conference on Interstate Milk Shipments.

Publication Permission Section

Permission is hereby granted to release and publish the above-stated rating or HACCP listing for use by State and Territorial Milk Control Authorities and prospective purchasers.

It is understood and agreed by the undersigned that the official rating or HACCP listing agency may review this supply at any time during the two-year period referred to above. It is further understood that we will notify the rating or HACCP listing agency if any significant change should occur, which affects our raw milk supply, milk plant, receiving station or transfer station status, including products listed.

It is understood and agreed that the failure to maintain the rating or HACCP System at a level, which is acceptable for listing, may result in immediate removal of this listing.

It is further agreed that plants, receiving stations or transfer stations, which receive milk or milk products for processing into products for which that plant receiving station or transfer station is listed, are from a non-listed source or a source having a milk sanitation compliance rating of less than 90% shall be immediately withdrawn from the Interstate Milk Shippers List.

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SIGN AND RETURN TO __________________________ WITHIN FIVE (5) DAYS OF RECEIPT.
(Name of Agency)

______________________________________________________________
Name of Shipper

______________________________________________________________
Signature of Representative

______________________________________________________________
Title

______________________________________________________________
Date

FORM FDA 2359o (10/06)