Fortenberry's 5739 Hwy 43 North, Carriere, MS 39426 601-798-2156 601-798-6930(Fax)
AGE VERIFICATION FORM FOR CATTLE CUSTOMERNAME: ___________________________________________________________ADDRESS: ________________________________________________________ ________________________________________________________PHONE NUMBER: __________________________________________________CELL PHONE NUMBER: ______________________________________________DESCRIPTION OF ANIMAL: _____________________________________________________________________________________________________________AGE OF ANIMAL: ___________________________________________________DELIVERY DATE: ___________________________________________________I, ___________________________________ will be responsible for determining the ageof my animal. If through the verification of dentition(age by teeth condition) by Fortenberry's,my animal is found to be over 30 months of age-I understand that I will be responsible forthe necessary removal of my animal.________________________________________ ___________________Signature of Responsible Party DateThis is in compliance with Annual Raw Material Supplier Certification/Undertaking [21 C.F.R. 589.2001 and 21 U.S.C. 331(h), 333].The expanded Food and Drug Administration Bovine Spongiform Encephalopathy(BSE) Rule, which prohibits the use of certaincattle origin materials in food or feed of animals. Collectively these materials are called "Cattle Material Prohibited from AnimalFeed" (CMPAF). Prohibited Materials or CMPAF include: (1) brains and/or spinal cords of cattle aged 30 months or older; (2)any part of the carcass of BSE-positive cattle; and (3) any part of the carcass of cattle aged 30 months and older which havenot been inspected and passed for human consumption and from which the brain and/or spinal cords have not been removed. 