FV-231-1 PACA License Renewal Application

PACA License Renewal Notice

FV-231-1 (03-06)

OMS Approved

0581-0031

INSTRUCTIONS:
Is all the information shown on the front of this form current and complete?
DYes
D
No If "No", report the changes or additions on the front or
in the appropriate space below, If the license is NOT being renewed, explain your reasons under "REMARKS." This form must be signed, returned with annual renewal fees, and
received by the anniversary date shown on the front of this form. Make checks payable to .USDA - AMS." Pleaseincludethelicensenumberbeingrenewedon thecheck.

Return Completed License Renewal Application and appropriate
USDA, PACA Branch
P.O Box 790327
St Louis, MO 63179-0327

fees bv mall to:

Type of Card:

Account Number:

Questions, Call (703)331-4570 or email PACASearchtO>.usda.aov
Visitour website at www.ams.usda.aov/fvlpaca.htm

Fresh

Frozen

o Mastercard o
o
o
Visa

Exp

Date:

AMEX

Diners Club

Discover

If pavina bv credit card, submit renewal bv fax to (703)330-4555

FRUITS AND VEGETABLES HANDLED
(Item 3 on front)
Circle One

o

_ _ __

----

_I_

----

Amount:

Card Holder's Name:

NATURE OF BUSINESS
(Item 4 on front) Circle the one that best represents the predominant nature of your operations

Both

Wholesaler

Commission Merchant

Broker

Retailer

Processor

Trucker

LEGALSTRUCTUREOF BUSINESS(Item5 on front)Haschangedto: CircleOne
Sole Proprietor Corporation Association Trust

Food Service

Grocery Wholesaler

I DATEOF CHANGE

Estate LimitedPartnership LimitedLiability Company Partnership

CHANGES IN OWNERSHIP, PARTNERS, OFFICERS, DIRECTORS, MEMBERS andlor MANAGERS OF LLCs AND STOCKHOLDERS Please update a/l information requested
%of
Date of
LEGAL NAME
FULL HOMEADDRESS
Changes
Social Security
Title (Including
Add Delete Change
Number
Stock
Last, First, Middle Initial
Director)
Street, City. State, Zip Code

Main Business

Changes
Add
Delete

Phone Number

Date of
Change

Fax Number

Trade Name (dba) or
Branch

E-Mail Address

Federal Employer Identification

Branch Locations
City and State

Number

SignatureandTitleof Owner,Partner,Member/Manager
(LLC)or Officer
completingthe PACALicenseRenewal
Signature
Title

Date

According to the Paperwork Reduction Act of 1995, an agency may not conduct or 'ponsor, and a person is not

REMARKS

required to respond to a collection of infonnation unless it displays a valid OMB control nunDer.
OMB control number for this information collection is 0581-0031.
The time required to co""lete

The valid
this

information collection is estimated to average 3 minutes per response, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data nceded, and completing and
reviewing the collection of infonnation. The U.S. Dcpanmcnt of Agriculture (USDA) prohibits discrimination
all its programs and Ittivities on the basis of race, color, national origin, age, disabtlity, and where applicable,
sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political
beliefs, reprisal, or because all or pan of an individual's income is derived tTom any public assistance program
(Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for
comnunication
of program infonnation (Braille, large print, audiotape, ctc.) should contact USDA's TARGET
Center at (202) 720-2600 (voice and TDD). To file a co""laint 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 opponunity provider and employer.

in

Form Approved. - OMS No. 0581 - 0031
According 10 lhe Paperwork Reduction
valid OMB control number. The valid
this information collection is estimated
data sources, gathering and maintaining

PACA LICENSE RENEWAL
APPLICA TION

The u.s. Depanment of Agriculture (USDA) prohibits discrimination in its programs on the basis of race, color. national origin, gender,
religion, age, disability, political beliefs. sexual orientation. and marital or family status. (Not all prohibited bases apply 10 all programs).
Persons with disabililies who require alternative means for communication of program information (Braille, large print.audiotape. etc.)
should contacl USDA's TARGET Center at 202-720-2600 ( voice and TOO). To file a eomplaint ofdiscriminalion,write
USDA. Direetor.
office of Civil Rights, Room 326.W, Whinen Building, 14ch and Independence Avenue, SW, Washington, DC 20250-94100r call (202)
720-5964 (voice and TDD). USDA is an equal opponunity provider and employer.

This PACA license eiXpireson anniversary
date listed in block 2 if not renewed
I. LICENSE

NO.

2, ANNIVERSARY
DATE

3. TYPE OF BUSINESS

: WILLIAM P HUTCHINSON

ATTN

4. NATURE OF BUSINESS

FROZEN FRUITS & VEG

02-05-2007

19027148

NOR PAC SERVICES

ACI of 1995. no persons are required 10 respond 10 a collection ofinfonnation unless it displays a
OMB control number for this information collection is 0581-0031. The time required 10 complete
to average 3 minutes per response. including the time for reviewing instructions, searching existing
the data needed, and completing and reviewing the collection information.

S. OWNERSHIP

WHOLESALE DEALER

PO BOX 458

2255

BUS:

Phone:

97383-0458

OR

(503)399-8019

I

Fax:

(503) 769-1945

HUTCHINSON JR WILLIAM P
JACOBSON

NOR PAC

ERIK

FOODS

N

INC

S

D

OR

PORTLAND

OR

KEIZER

OR

I

EDER JOSEPH H

Il1084 WEST STAYTON
AUMSVILLE

RD SE

HOOK RD NE

CARL

SEBASTIAN J J

D
I

I

D

I

D

I

D

I

OR
POBOX

I

308

I

STAYTON

OR

SALEM

OR

I
I

100.00

OR

ALBANY
HENDRICKS

I

OR

HARNISCH DR NE

32920
I

SH

I

MT ANGEL
CHAMBERS RODNEY

PDCEO

OR

12639
I

S

I

SALEM
KEUDELL ALAN

1,650.00
S
01-01-1931

I

I
I

1,100.00

I

I
I

550.00

S

3 YEAR RENEWAL
FEES DUE
DATE INCORPORATED

I
I

.00

S

D 2 YEAR FEES
RENEWAL
DUE

Email:

STATE IN WHICH INCORPORATED
FORMED
OREGON

EIN:

S

BRANCH
MULTIYEAROPTIONS
("X" one box)

97302-1111
I

550.00

BASIC

FEES DUE

MADRONA AVE S E

SALEM

0

NOTICE TO LICENSEE
THIS IS A BILL. Failureto return this Formand
fee by the anniversarydate will result in an additional
$50 fee. COMPLETE REVERSE SIDE
RENEWAL FEES

JR

OR

6. NO. OF
BRANCHES

CORPORATION

INC

STAYTON

TYPE

I

VPFCFO

NOTICE TO LICENSEE - You .r~ IiceDud under the Perishable Agricultura. Commodities Act IS described above. If you are continuing in business,lubj«t to the Ad. you must renew the license for another yeu. This
nne"'.' .ppliullon mUlt be signed on the reverse and mUlt reach this office by the anninnuy date shown abon. See reverse (or Inslructionl on how 10report change. in your bu.iness oper.lion.,If any hur occurred.
PENALTIES: Opentionl without .license could relYI. In an Injunction plul' civil penalty orSI200 for neh offense plul 5350 for each day the offense conUnue..
Make check payable 10 USDA-AMS
FV-23J-1
(10-02)
CG:IIFDL

Relurn rorm with paymenllo:
USDA -PACA Branch
P.O.BOX 790327
SI. Louis MO 63179 - 0327

Notice 10 Customul
Making Payment by Check: As pan ofa Dcpanmcnt of Treasury initiative, if you pay your account by check, it will be convened into an electronic funds
transfer(EFT). This means the bank will copy your check and use the account information on it to electronically debit your account for the amount of the check. The debit from your
account will usually occur wilhin 24 hours, and will be shown on your regular bank account statement. You will not receive your original check back. The bank will destroy your original
check. bul will keep Ihe copy of it. If the EI-,. cannot be processed for technical reasons, you authorize us 10 process Ihe copy in place or your original check. Iflhe EFT cannnol be
completed because of insufficienl funds. the bank may try (0 make me transfer up to 2 times at which point your account will be subject to additional administrative charges.