FV-231-2 PACA License Renewal Application

PACA License Renewal Notice for Grocerv Wholesalers and Retailers
Is all the information shown on the front of this form current and complete?

Yes

D NoD

INSTRUCTIONS:
If any of the information shown on the front of this form is NOT current or correct, 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, and received by the anniversary date
shown on the front of this form.

Return ComDleted License Renewal ADDlication bv fax or mail to:
USDA, PACA Branch, National License Center
8700 Centreville Road, Suite 202
Manassas, VA20110-8411
Fax: (703)330-4555
FRUITS AND VEGETABLES HANDLED
Circle One
(Item 3 on front)
Fresh

Frozen

Questions, Call (703)331-4570

or email [email protected]

Visit our website at www.ams.usda.aov/fv/Daca.htm

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

Both

Wholesaler

Commission Merchant

Broker

Retailer

Processor

Trucker

Corporation

Association

Trust

Estate

Grocery Wholesaler

DATE OF CHANGE

LEGAL STRUCTURE OF BUSINESS (Item 5 on front) Has changed to: Circle One
Sole Proprietor

Food Service

Limited Partnership

Limited Liability

Company

Partnership

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

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 sponsor, and a
person is not required to respond to a collection of information unless it displays a valid OMB control

REMARKS

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, 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, or political beliefs.
(Not all prohibited bases apply to all programs.) Persons wllh 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.

PACA License Renewal Notice for Grocerv Wholesalers and Retailers
Is all the information shown on the front of this form current and complete?

Yes

D NoD

INSTRUCTIONS:
If any of the information shown on the front of this form is NOT current or correct, 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, and received by the anniversary date
shown on the front of this form.

Return ComDleted License Renewal ADDlicationbv fax or mail to:
USDA,PACABranch, NationalLicense Center
8700 CentrevilleRoad, Suite 202
Manassas, VA20110-8411
Fax: (703)330-4555
FRUITS AND VEGETABLES HANDLED
Circle One
(Item 3 on front)
Fresh

Frozen

Questions, Call (703)331-4570

or em ail [email protected]

Visit our website at www.ams.usda.aov/fv/oaca.htm

NATURE OF BUSINESS
(Item 4 on front) Circle the one that best represents the predominant style of your operations
Wholesaler Commission Merchant
Broker
Retailer
Processor
Trucker
Food Service

Both

LEGAL STRUCTURE OF BUSINESS (Item 5 on front) Has changed to: Circle One
Sole Proprietor

Corporation

Association

Trust

Estate

Grocery Wholesaler

DATE OF CHANGE

Limited Partnership

Limited Liability

Company

Partnership

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

Main Business Phone Number

Changes
Add
Delete

Date of
Change

Fax Number

Trade Name (dba) or
Branch

E-Mail Address

Federal Employer Identification Number

Branch Locations
City and State

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 sponsor, and a

REMARKS

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 0581-0031.
The time
required

to complete

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 needed, and completing and reviewing the collection of information.
The U.S. Department of Agricullure (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, or political beliefs.
(Not all prohibited bases apply to all programs.) Persons with disabilities who require altemative
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.