Form 79-009A Poultry Meat Inspector License Application - California

Form 79-009A is a California Department of Food & Agriculture form also known as the "Poultry Meat Inspector License Application". The latest edition of the form was released in August 1, 2014 and is available for digital filing.

Download a PDF version of the Form 79-009A down below or find it on California Department of Food & Agriculture Forms website.

ADVERTISEMENT
STATE OF CALIFORNIA
DEPARTMENT OF FOOD AND AGRICULTURE
Meat, Poultry and Egg Safety Branch
Distribution:
1220 N Street
1 - Headquarters (Original)
Sacramento, CA 95814
2 - Inspector (Copy)
3 - Area Supervisor (Copy)
(916) 900-5004
79-009A (Rev. 08/14)
Date:
POULTRY MEAT INSPECTOR LICENSE APPLICATION
FEE $100.00
In accordance with Section 25052, Article 4, Chapter 3, Division 12, of the California Food and Agricultural Code,
application is hereby made for a Poultry Meat Inspector (PMI) license . Please Print with CAPITAL LETTERS.
Applicant First Name:
Last Name:
Mailing Address:
City, State, Zipcode:
Home Phone:
Work Phone:
FAX :
E-Mail Address:
Sex:
F
M
Height:
'
"
Date of Birth:
Weight:
lbs. Hair:
Eyes:
Do you speak and/or understand English?
Yes
No
If not, what language(s) do you speak and/or understand?
ATTACH TWO RECENT PHOTOGRAPHS [Color photographs only; size should be approximately 1" x 1 1/4"
(passport photo size); frontal view of face; use tape on the back of picture, do not use glue or staples.]
Tape Photo Here
Tape Photo Here
Plant name and address where PMI training and written, oral, and demonstration examinations can be given:
I understand the authority vested in this license is restricted to use in Poultry Plants licensed in California.
Licenses will be issued by the Department only to qualified persons who have passed written, oral, and demonstration
examinations. Any changes in information provided above must be reported to the Meat, Poultry and Egg Safety
Branch within 15 days. Obtaining all information requested is mandatory and required before a license can be issued
according to requirements in Division 9 of the California Food and Agricultural Code.
Mail application and one-hundred dollar ($100.00) fee to: Cashier, Department of Food and Agriculture,
1220 N Street, Sacramento, CA 95814. Please retain a copy for your records.
Printed Name of Applicant:
Signature of Applicant:
I declare under penalty of perjury that the information provided on this application is true and accurate to the best of
my knowledge.
STATE OF CALIFORNIA
DEPARTMENT OF FOOD AND AGRICULTURE
Meat, Poultry and Egg Safety Branch
Distribution:
1220 N Street
1 - Headquarters (Original)
Sacramento, CA 95814
2 - Inspector (Copy)
3 - Area Supervisor (Copy)
(916) 900-5004
79-009A (Rev. 08/14)
Date:
POULTRY MEAT INSPECTOR LICENSE APPLICATION
FEE $100.00
In accordance with Section 25052, Article 4, Chapter 3, Division 12, of the California Food and Agricultural Code,
application is hereby made for a Poultry Meat Inspector (PMI) license . Please Print with CAPITAL LETTERS.
Applicant First Name:
Last Name:
Mailing Address:
City, State, Zipcode:
Home Phone:
Work Phone:
FAX :
E-Mail Address:
Sex:
F
M
Height:
'
"
Date of Birth:
Weight:
lbs. Hair:
Eyes:
Do you speak and/or understand English?
Yes
No
If not, what language(s) do you speak and/or understand?
ATTACH TWO RECENT PHOTOGRAPHS [Color photographs only; size should be approximately 1" x 1 1/4"
(passport photo size); frontal view of face; use tape on the back of picture, do not use glue or staples.]
Tape Photo Here
Tape Photo Here
Plant name and address where PMI training and written, oral, and demonstration examinations can be given:
I understand the authority vested in this license is restricted to use in Poultry Plants licensed in California.
Licenses will be issued by the Department only to qualified persons who have passed written, oral, and demonstration
examinations. Any changes in information provided above must be reported to the Meat, Poultry and Egg Safety
Branch within 15 days. Obtaining all information requested is mandatory and required before a license can be issued
according to requirements in Division 9 of the California Food and Agricultural Code.
Mail application and one-hundred dollar ($100.00) fee to: Cashier, Department of Food and Agriculture,
1220 N Street, Sacramento, CA 95814. Please retain a copy for your records.
Printed Name of Applicant:
Signature of Applicant:
I declare under penalty of perjury that the information provided on this application is true and accurate to the best of
my knowledge.

Download Form 79-009A Poultry Meat Inspector License Application - California

1469 times
Rate
4.6(4.6 / 5) 88 votes
ADVERTISEMENT