FV-202 Application for Interstate/Intrastate Commerce Inspector

OMB APPROVED – NO. 0581-0125

REPRODUCE LOCALLY, Include form number and edition date on all reproductions

U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
APPLICATION FOR
INTERSTATE/INTRASTATE
COMMERCE INSPECTOR’S
1/
LICENSE

The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a). According to the Paperwork Reduction Act of 1995, an
agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a valid OMB control number.
The valid OMB control number for this information collection is 0581-0125. The time required to complete this information collection is estimated to
average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the date
needed, and completing and reviewing the collection of information
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age,
disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs,
reprisal, or because all or part of an individual’s income is derived from any public assistance program (Not all prohibited bases apply to all programs.)
Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact
USDA’s TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400
Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity
provider and employer.

NOTE: Applicants for this License must have at least 36 months of fresh fruit and vegetable grading experience as a USDA Licensee.
1. NAME (Last, First, Middle)

2. SOCIAL SECURITY NUMBER

3. BIRTHDATE (Month, Day, Year

4. MAILING ADDRESS (City, State, Zip)

5. CURRENT DUTY STATION (City, State, Zip)

6. IMMEDIATE SUPERVISOR’S NAME (Last, First, Middle)

7. TELEPHONE NUMBER

8. LIST ALL STATES IN WHICH YOU HAVE BEEN LICENSED AND SHOW THE TOTAL NUMBER OF MONTHS YOU WERE LICENSED BY THAT STATE:
STATE(S)
MONTHS
STATE(S)
MONTHS
STATE(S)
MONTHS
STATE(S)
MONTHS
STATE(S)
MONTHS
STATE(S)

MONTHS

9. LIST ALL PREVIOUS EMPLOYERS FOR THE PAST FIVE YEARS (If additional space is required, use back of this form:
EMPLOYER’S NAME

EMPLOYER’S ADDRESS (City, State, Zip)

10. DID YOU GRADUATE FROM HIGH SCHOOL (if you have a GED, answer yes)?

DATE BEGAN

YES

DATE ENDED

NO

11. IF NOT, WHAT IS THE HIGHEST GRADE THAT YOU COMPLETED?
12. HAVE YOU ATTENDED COLLEGE (if yes, list below all colleges attended, use back if needed)?
NAME OF COLLEGE

YES

NO

COLLEGE ADDRESS (City and State)

13.

LIST CHIEF UNDERGRADUATE SUBJECTS:

14.

APPLICANTS SIGNATURE

TYPE OF DEGREE OR TOTAL
SEMESTER HOURS

DATE

By signing above, I agree to abide by all Federal instructions governing the inspection of fruits and vegetables, whether given to me in writing (handbooks, memorandums, etc.) or orally
by the Federal Program Manager/Supervisor. I also agree to surrender my license card when so requested by the Federal Supervising Inspector or upon termination of my employment
with my current employer.
THE FOLLOWING TO BE COMPLETED BY APPROVING OFFICIALS ONLY
FEDERAL PROGRAM MANAGER / SUPERVISOR’S SIGNATURE

CHECK ONE

Unrestricted License

DATE RECOMMENDED

Other (Specify)

Restricted License – to what commodities?

The state concurs in the need for an unrestricted license and agrees to send the applicant to a Federal Market Training class within two years from date of approval and to
provide other training as deemed necessary by the USDA Fresh Products Branch Chief.

STATE MANAGER’S SIGNATURE:

DATE:

REGIONAL DIRECTOR’S SIGNATURE:

Concurrence

Disapproval

FV-202 (9/06) Destroy previous editions.

DATE APPROVED:

BRANCH CHIEF’S SIGNATURE:
1/

DATE:

As defined in the Manual for Federal and Federal-State Shipping Point Supervisors, October 1992, and other Branch Directives, FPB-02 (01-94)