Form CAC 100 CAC 100 Citrus Grown in FL. Application for Repacking Certificat

CAC Form 100

20XX-XX SEASON
OMB No. 0581-0189

Citrus Administrative Committee
P.O. Box 24508, Lakeland, FL 33802-4508
Phone 863-682-3103
Fax 863-683-9563
[email protected]

Application for a Repacking Certificate of Privilege
As required by Federal Marketing Order No. 905 regulating shipments of Fresh Florida Citrus
_______________________________________________________________________
Business name on Citrus Fruit Dealer’s License
_______________________________________________, __________________________ FL ___________________
Address
City
Zip

Phone # - (_______) - __________________________ Fax # - (_________) - __________________________

Hereby certifies and agrees to the following:
1.

I (we) have obtained a license as a Citrus Fruit Dealer and request a Certificate of Privilege as a Special Purpose
Shipper from the date of this application to
.
(Citrus Fruit Dealer’s License Number _______________)

2.

I (we) will deal only with fruit which, has been positive lot identified inspected and certified as defined in Section
905.53 of Federal Marketing Order No. 905.

3.

All citrus fruit handled by me (us) will be from registered packinghouses.

4.

I (we) hereby submit a list of suppliers of inspected and certified Florida citrus fruit described in item 2 above and
the approximate number of boxes of Florida citrus fruit that will be handled during the season. (Please attach
separate sheet(s) showing supplier’s business name address and packinghouse registration number.)

5.

Citrus shipped under a Repacking Certificate of Privilege will meet the following requirements: (a) the applicable
minimum grade ands size requirements under Marketing Order No. 905; (b) all fruit shall have been inspected by
the Federal or Federal State Inspection Service prior to the time such fruit is received; (c) All citrus fruit handled
shall be packed in approved Florida Department of Citrus containers (d) be reported to the Committee as required
in Section 905.163, Reports of Shipments under Repacking Certificate of Privilege.

_______________________________________________________
Authorized Signature of Licensed Citrus Fruit Dealer

___________________________
Title

______________
Date

False certification, or knowingly making any false statement, to the Secretary of Agriculture is a violation of Title 18,
Section 1001, of the United States Code, and is punishable by fine not exceeding $10,000, five years’ imprisonment, or
both 96-25-48, c 645, 62 STAT. 749

(See Reverse Side)

CAC Form 100
Page 2

OMB No. 0581-0189

Application for a Repacking Certificate of Privilege

Date: __________________________________-

The above application for a Repacking Certificate of Privilege is hereby approved (disapproved) for the period through
.
. For the 20XX-XX season you will be Repacking Certificate of Privilege No.

By:

__________________________________________________
Manager, Citrus Administrative Committee

FAILURE TO COMPLY WITH ANY OF THE CONDITIONS STATED IN THIS DOCUMENT WOULD BE
GROUNDS FOR IMMEDIATE TERMINATION OF THIS CERTIFICATE OF PRIVILEGE.

Note: The following statements are made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a) and the Paperwork Reduction Act of 1995. The authority for
requesting this information to be supplied on this form is the Agricultural Marketing Agreement Act of 1937, Secs. 1-19, 48 Stat. 31, as amended, (7 U.S.C. 601-674).
Furnishing the requested information is necessary for the administration of the marketing order program.
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 0581-0189. The time required to complete this information
collection is estimated to average 7 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.