Form FV-DOVS-1 Domestic Origin Verification application for Service

OMB No. 0581-0234

Domestic Origin Verification (DOV)

APPLICATION FOR SERVICE

Name and Address of Facility Where Audit Services Are Requested:  
Billing Address      
List the components and products that are requested for DOV program approval (Fruit, nut, or vegetable components and/or products):      
Check Appropriate Domestic Origin Status: Process and/or handle ONLY domestic fruit, nut, and vegetable components or products, including components or products from suppliers that are similar to that delivered to the United States Department of Agriculture (USDA), Agricultural Marketing Service (AMS). Process and/or handle domestic and non-domestic fruit, nut, and vegetable components or products that may include finished product from suppliers that are similar to that delivered to the USDA. Non-domestic components and products and those “not established” as domestic are controlled by a written Segregation Procedure.
I (we) agree: To comply with all applicable provisions of the General Terms and Conditions of the Procurement of Agricultural Commodities or Services, and Commodity Procurement Branch (CPB) announcements, specifications, and invitations. To allow reasonable access to facilities and provide all documentation or records within the scope of the DOV program. To immediately notify the DOV Coordinator when it (1) implements or changes a procedure to control components or products that are received or purchased, or to segregate domestic from non-domestic including those “not established” as domestic; or (2) changes the domestic origin status as stated on the application; or (3) changes the components or products noted in this application. To immediately notify the USDA, AMS, Fruit and Vegetable Programs (F&V), CPB and the nearest PPB Field Office when non-conforming components or products are shipped to the USDA. To provide a completed DOV Application for Service and related verifiable written procedures. To respond to Corrective Action Requests. To suspension or denial from DOV program approval if deemed in the best interest of the USDA, AMS. Reasons for suspension or denial of approval include, but are not limited to, the inability to provide the required domestic origin documentation, a request by CPB to suspend the applicant for inability to meet contract requirements, or customer complaints. To authorize posting of information regarding this approval on the USDA Internet website. Signing this application provides the authorization to post the applicant’s information on the website. If you do not want your company’s name posted on the web, please check . To pay all applicable fees associated with this auditing service.
Signature of Applicant or Representative:  	Title of Applicant Representative:  			Date:      
Print or Type Name of Signer:      		Telephone No.:      	E-mail address of Applicant’s Representative:      

Return the application and related documents to: E-mail: [email protected]

USDA, AMS, FV, DOV Coordinator Telephone: (785) 336-0267

409 North Street Fax: (785) 336-0238

Seneca, KS 66538

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 0581-0234. The time required to complete this information collection is estimated to average 1 hours 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.

FV-DOV-1 (07-07)