Form FV-211 Application for License

FV-211(04-06)

OMB

UNITEDSTATES DEPARTMENT OF AGRICULTURE

USDA

AGRICULTURAL MARKETING SERVICE

APPLICATION FOR LICENSE
(Underthe PerishableAgriculturalCommoditiesAct, 1930)

- 0581-0031

Approved

For questions or to apply by phone call'
(800)495-7222
PACA Website:
http://www.ams.usda.gov/fv/paca.htm

requested on this form is requ8'ed IA'Iderthe Perishable AgricuItlnI Commodities Ad. (7 CFR ~.4) for the issuance of a license. The information contained in this form will be used by Federal, State,
local, a- foreign agencies when relevant to civil, aiminal, a- regulatory investigations a- procedures. Faillft to provide the infonnation required will result in delay a- suspension of the processing of this form.

The information

1a. Name of Business (Full LegaH"ame of Business registered under EIN)
3. Web Site

2. Federal Employer Identification Number (EIN)

4a. Physical Business Address (Post Office Box NOT ACCEPTABLE)
Street Address

State

City
Telephone Number (With Area Code)

Zip Code+4

IFax Number (With Area Code)

" here if same as Business Address):

0
-

Street Address (Post Office Box Number)
State

City

Zip Code+4

Trade Name

6a. Legal Structure (see page 4 for explanations)

D

Sole Proprieter

o

Corporation(see 6b)

Attention:

State

City

6b. Completeonly ifyou checked Corporation or LLC
state
uate OTmcorporationJurgamzatlon

D LimitedPartnership
6c. Completeonly ifyou checked LLC

o
D
o
D Operating Agreement is included with application
o
D Limited Liability Company (LLC) (see 6b and 6e) 8. Primary Nature of Business: (see page 4 for explanations)
o Limited Liability Partnership (LLP)
o Broker
D
D
Estate

Articles of Organization

is included with application

Partnership

Trust

7.Types of Fruits and Vegetables Handled by Applicant

o Fresh
o Frozen

D Fresh and Frozen
FV.211(11-06)

D CommissionMerchant 0
D FoodService

o

Grower

o Growers' Agent

o

Processor

Retailer

Shipper

D Grocery
Wholesaler

Trucker

D Wholesaler
Page 1 of4

9. List Principals, Owners,-and StockholderS hOlding more than 10% of stoCk (REQUllfEDJ
List below the requested information for Individual Owner, All Partners, Members anellor Managers of LLCs, Officers
(Including Titles), Directors, Trustee, Guardian, and Stockholders holding more than 10 percent of
outstanding voting stock. If any person listed is a minor, furnish the name of His/Her guardian. If any person listed is
a trust,furnish the name of the trustee. If any person listed is an estate, furnish the name of the Executor/Executrix.
(Attach a separate page for additional entries)
ame
oCla
Last Name (Prinro;;-r:irstUne)
Security
First Name and Middle Initial
Number

123-45-7890

~~----------JOIlllA.

JtOwn, JJC12J6"-7Rgij"

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-----------

-----------

-----------

-----------

-----------

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-----------

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--

President

75%

10. Has the applicant or any person listed in Question 9 filed bankruptcy, been discharged as a bankrupt, or been an
officer, director, shareholder,
partner, member/manager
(LLC), or owner of a firm that has filed bankruptcy or been
discharged as bankrupt?

If Yes, Identify the firm or Individual (PACA license number, if possible), the name and
address of the firm involved, and details about bankruptcy. Submit a copy of the bankruptcy
petition,schedules, disclosure statements, and all other relevant documentation. (Attach a

separate sheet for additional space)

11.Hasany person listed in Question 9 been convicted of a felony in any State or Federal Court?

YesD

NoD

If Yes, furnish the name, date of birth, and alias (if any), of the indlvidual(s), if any. FOR ALL
CONVICTIONS,provide the name and location of the court, date convicted, nature of the
felony, sentence imposed, where served; If paroled, give date terminated or will terminate.
(Attach a separate sheet for additional space)

12.Hasany person currentlyemployed by the applicant been the Individualowner, partner, officer,director, or holder of more than
10 percent of the outstanding voting stock of a firm, association, or corporation, or a memberl manager (LLC)whose PACA
license Is under suspension; been revoked; found to have committed any flagrant or repeated violation of the PACA, or against
which there is an outstanding unpaid reparation award?
Yes

Jd

No 1.0 If Yes, furnish the full name of the person, name of the firm Involved (PACA License number
If possible), and details of such connection, Including the dates thereof. (Attach a separate

sheet for additional space)

FV~n1 (04-06)

Page 2 of 4

13.ls the applicant currently operating at volumes requiring a PACA Ucense? (See Page 4 for Nature of Business explanation,
YesD

SCHEDULE A

No

0

If Yes, provide the date applicant first met that volume.

Brokers, Commission Merchants, Food Services, Growers, Grower's Agents,
Processors, Shippers, Truckers, and Wholesalers. All others see Schedule B)

(Includes:

License Fees

Annual License Fee:

$

Branch Fee: $200 for each Branch over 9 (Maximum $3450)

$
$

550.00
550

Total Fee per Year
Number of Years for
License (Maximum 3)

Multiplied by

$
Accrued

Fees for Previous

Operations

0

Total License Fee

(No more than 2 years)

Monthly License Fee:
Monthly Branch Fee: $16.67 for each branch over 9 (Maximum $287.50)

$ 45.83
$

$

0.00

Total Fee per Month
Number of Months
(Maximum 24)

Multiplied by
$

Total Fees for

000

Previous Operations
(Total License Fee

+

0.00

Total Fees for Previous Operations) S

Total Amount

Due

SCHEDULE B (Retailers and Grocery Wholesalers Only)
Adminstrative Fee for Initial Application

100.00

$

(Retailers and Grocery Wholesalers that have been previously licensed are not required to submit additional administrative fees)

PAYMENT

-

Checks: Make Checkspayable to .USDA AMS.
Credit Cards:
Type of Card
D Visa D Mastercard

Amount:

D

AMEX

Account Number:
Card Holder's Name:
Application must be signed by the Owner, all Partners, all General Partners,
the Trustee, Executor1Executrtx, a MemberlManager (LLC),or a Corporate

Discover

D

Diners Club

Exp Date:
CERTIFICA TION STATEMENT
I (We)certifythat the answers given to the foregoing questions are true to the
best of my (our) knowledge. Applicantagrees not to loan or transfer
possession of the license certificateto any person or firmwhatsoever.
Signature(s):

FV.211(11-06)

D

0.00

Date:

Page 3 of 4

DEFINITIONS AND TERMS
Dealer (illcludes wholesalers, jobbers, distributors, and growers who marltet produce grown by others) means any person engaged in the business ofbuyiDg or selling in wholesale or jobbing quantities,
as defined by the Secretary, any perishable agricultural commodity in interstate or foreign commerce. A person who buys potatoes for canning or processing is a dealer whether the potatoes are purchased
within the state or ill illterstate or foreign commerce.
Interstate or Foreign Commerce
Wholesale

or Jobbing Quantities

means all transactions
means agregate

involving fresh and frozen ftuits and vegetables which move between states, andfor other countries and the U.S.

quantities of all types of produce totaling ODeIon (2,000 pounds) or more in weight in any day sbipped, received, or contrIcIed 10 be shipped or received.

Branch or Additional Busilless Facility means an office or outlet in a location other than that of the principal or main office of a firm, out of which or through which the firm purchases,
contracts, solicits, or handles consignments, or otherwise contracts in perishable agricultural commodities including seasonal, part-time and full-time operations.

ATURE OF BUSINESS: (See Question 8)

LEGAL STRUCTURES: (See Question

sells, negotiates

60)

The following are definitions of the types of dealers, brokers and commission
merchants that are required to have a PACA license.

Individually owned or Sole Proprietorship
responsible for all activities.

Wholesaler,

Corporation is authorized by state law to act as a single entity and is registered with the secretary/
corporation commission of a state. The corporation can have elected officers and directors, an
appointed registered agent and shareholders. Shareholders can be iIIdividuals, other corporations,
LLC, partnerships, etc.

see Dealer (above)

Foodservice is a dealer that purchases and sells fresh andfor frozen ftuits and vegetables in interstate
or foreign commerce for distribution 10 restaurants, institutions, convenience stores, etc. These
operations commonly also sell non-subject items as well.
Processor is a dealer that purchases fresh andfor frozen ftuits and vegetables ill interstate or foreign
commerce for canning or processing or sells product in interstate or foreign commerce that has not
had its kind or character changed (i.e., salad mixes, sliced ftuil, vegetables, frozen or packed in ice or
consists of cherries In brine, etc.). However, a processor Is not subject If the purchasing and
processing which changes the kind and character are both accomplished
within the State where
the produce is grown, even If the processed product Is shipped out of the State.

Shipper Is a dealer who operates at shipping point and is engaged in the business of purchasing
produce from growers or others and distributing such produce in commerce by resale or other
methods, or who handles such produce on joint account with others.
Trucker Is a dealer that purchases and setls fresh and/or frozen fruits and vegetables in Interstate
or foreign commerce from its truck not as a retailer.
Retailer is a dealer when it purchases wholesale and jobbing quantities, but is only subject to a PACA
license when the iIIvoice cost of all purchases of produce (including frozen potato products such as
French fries) exceeds $230,000 during a calendar year. In computing dollar volume, all purchases of
IRsh and frozen ftuits and vegetables are to be counted, without regard to quanoty involved in the trnnsaxtion
or whether the transaction was intras1ate, intastate or foreign COtII1IICII:e.

Grocery Wholesaler is a dealer primarily engaged in the full-line wholesale distnbution and resale
of grocery and related nonfood items (such as perishable agricultural commodities, dry groceries,
general merchandise, meat, poultry, and seafood, and health and beauty care items) to retailers. This
term does not Include persons primarily engaged In the wholesale distribution and resale of
perishable agricultural commodities rather than other grocery and related nonfood items.
Spedfically, for an entity to be considered a grocery wholesaler, SOpercent or more of its annual
gross sales must be from the fulHine distribution and resale of grocery and related nonfood items,
and it cannot have more than SOpercent of its sales In perishable agricultural commodities. "Fullline" means that an entity must be supplying the retailer with a wide range of products such as the
grocery and related nonfood items specified.
Broker means any person engaged in the business of negotiating sales and purchases of any
perishable agricultural commodity in illterstate or foreign commerce for or on behalf of the vendor
or the purchaser, respectively. The 2000 pound quantity limitations do not apply to brokers. They
are subject to PACA lM:ensing with their first interstate or foreign commerce transaction. It is
common in the iIIdustJy 10 have fresh produce brokers and frozen produce brokers. Frozen produce
brokers who negotiate contracts for frozen commodities exclusively for the vendor and the invoice
value of the vendor's product does nOl exceed $230,000 in a calendar year are not subject; however,
frozen produce brokers that are negotiating conlIacts for the buyer are subject no matter the invoice price.

Commission Mermant means any person engaged in the business of receiving in interstate or
foreign commerce any perishable agricultural commodity for sale, on commission, or for or on
behalf of another. For example, a person who receives a truckload of tomatoes; setls the product
for a grower; charges a commission; and remits the net proceeds to the grower. The 2000 pound
quantity limitations do not apply.
Grower is a business that grows its own ftuits and vegetables and is not required to be licensed.
However, a grower can be lic:eused on a voluntary basis and must comply with the PACA law while
licensed.
Growers' Agent means any person operating at shipping point who sells or distnbutes produce in
commerce for or on behalf of growers or others and whose operation may include the planting,
harvesting, grading, packing, and furnishing containers, supplies, or other services. The 2000 pound
quantity limitations do not apply, because this type of business is considered a type of commission
merchant.

FV-211 (11-46)

means one person has complete ownership

and is fully

Limited Liability Company or "LLC" is a form of a legal entity where the state law provides for a
firm to be treated as a partnership for tax purposes, while receiving the benefits from personal
liability usually associated with a corporation. LLCs are also registered with the secretary/
cotporation commission of a state. NOTE: LLC's are required to submit a copy of their Articles of
Organization and Written Operating AgreemenJ with the application.

Partnership is a voluntary contract between two or more persons who agree to carry on any
business or venture together, upon the terms of mutual participation ill its profits and losses, this
can be a verbal or written agreement. NOTE: Any change in partners will require a new license.
Limited Partnership is a partnership consisting of one or more general partners, jointly and
severally respousible as ordinary partners, and by whom the business is conducted, and one or
more special (limited) partners, contributing ill cash payments a specific sum as capital, and who
are nOlliable for the debts of the partnership beyond the funds contributed. Limited partnerships
are required to be registered with the secretary/corporation
commission of a state. NOTE: A
change in any general partner will require a new license. change in any general partner will
require a new license.
Limited Liability Partnership or "LLp. is a form of a legal enoty where the state law provides for a
firm to be treated as a partnership for tax purposes, while its individual partners receive protection
against personal liability of certain partnership liabilities. LLP's are also registered with the
secretary/corporation
commission of a state.
Association is commonly referred to as a Cooperative Marketing Association; a body of persons
united and sometimes acting together without a charter ill the pursuit of some common enterprise;
basically a large partnership, but differs from a partnership in that it is not bound by the acts of
the individual partners, but only by those of its manager(s) or trustee(s). NOTE: While PACA
exempts growers from the licensing ~irements,
cooperative mariceting associations must be
licensed. even if the produce being handled is that solely of its members.

Trust Is a right of property, real or personal, held by one party for the benefit of another; any
arrangement whereby property Is transferred with intention that It will be administered by a
trustee for another's benefit
Estate is the property, real or personal,
law to heirs at that person's death.

which a person

has a right or interest

and descends

by

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
ontral number. The valid OMB control number for this information collection is 0581-0031. The
time required to complete this information collection is estimated to average 3 minutes per
response, including the time for reviewing instructions, searchiDg existing data sources, gathering
and maintaining the data needed, and completiDg and reviewing the collection of information. The
U.S. Department of Agriculture (USDA) prohibits discrimination ill all its programs and activities
on the basis ofrace, 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 hases apply to all programs.) Persons with disabilities who
require alternative means for communication of program information (Braille, large prillt,
audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TOD). To
file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400
Independence Avenue, SW., Washington, D.C. 20250-9410, or call (goo) 795-3272 (voice) or
(202) 720-6382 (1DD). USDA is an equal opportunity provider and employer.

PENALTY:

Any person who operates without a valid and
effective license shall be liable to a penalty of not
more than $1,200for each such offense and not more
than $350for each day it continues.
Page 4 of 4