FV-237 Record of Request for Inspection/Reinspection of Food Pr

UNITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

FRUIT AND VEGETABLE PROGRAMS

FRESH PRODUCTS BRANCH

REQUEST FOR: INSPECTION REINSPECTION APPEAL INSPECTION AUDIT

(This is the only acceptable form for fax or electronic submission to USDA for inspection/audit requests)

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 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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: Fill in all appropriate blocks; blocks with “*” must be completed. Inspection may be delayed because of incomplete information. Type of Inspection must be selected above.

*Applicant’s (Company) Name:				*Date:
*Street Address:				*Time:
*City, State & Zip:
*Contact Person:				Type of Carrier:
*Phone Number:				Type:		Car Number or License Number:
*E-Mail Address:
Enter when different from Applicant:	*Shipper’s Name:			Car:
	City and State:			Trailer:
	Receiver’s Name:			Lot Inspection
	City and State:
*Location of Product(s):				Applicant’s P.O. Number:

Lots Separated by (Optional):	*Inspection Requested For (Must select at least one):
PLI Numbers	Quality and Condition (including size when applicable)
Grower Numbers	Condition Only
Size	Size
Other, Specify:	Net Weight
Digital Images Requested: Yes No	Other, Specify:
	Auditing Services (Please fill out page 2):

Products To Be Inspected
*PRODUCTS	BRANDS/MARKS	*QUANTITY	Type Container	*Size	Type/Variety

Remarks/Special Instructions;

FV-237 (03/07) Page 1 of 2 (Previous editions may be used)

UNITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

FRUIT AND VEGETABLE PROGRAMS

FRESH PRODUCTS BRANCH

REQUEST FOR GOOD AGRICULTURAL PRACTICES & GOOD HANDLING PRACTICES AUDIT

(Only fill out this page if requesting an Audit)

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 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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: Fill in all appropriate blocks; blocks with “*” must be completed. Audit may be delayed because of incomplete information.

* Company Name:
*Street Address:
*City, State & Zip:
*Phone Number:
*Contact Person:
*Phone Number(s) of Contact Person:
*E-Mail Address:
Website (if applicable):

*Please Choose One: USDA GAP & GHP Audit

USDA GAP & GHP Audit for Processed Products Branch QTV Program

Client Requested GAP & GHP Audit

Note: When choosing the USDA audits, the USDA checklist will be used. When choosing the Client requested audit, USDA will audit using a checklist supplied by the client.

The GAP & GHP Checklist and scoresheet is available on the USDA website: http://www.ams.usda.gov/fv/fpbgapghp.htm

* Check which sections of the GAP & GHP audit the farm/facility will be audited to and commodities covered:

Part 1 Farm Review		List Commodities being Reviewed
Part 2 Field Harvest & Field Packing Activities
Part 3 House Packing Facility
Part 4 Storage and Transportation
Part 5 Traceback
Part 6 Wholesale Distribution Facility/Terminal Warehouse
Part 6a Traceback
Part 7 Food Defense

Does the company have more than one facility that will be audited? (circle one) Yes No

Has the company had a USDA GAP & GHP before? (circle one) Yes No

Total acres farmed:

Remarks/Special Instructions:

FV-237 (03/07) Page 2 of 2 (Previous editions may be used)