FV-159 Application for Unofficial Samples

U.S. DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

APPLICATION FOR INSPECTION OF UNOFFICIALLY SUBMITTED SAMPLES OF PROCESSED FOOD PRODUCTS

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 0581-0123.  The time required to complete this information collection is estimated to average 2 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.

TO:  Processed Products Branch

        Fruit and Vegetable Programs

_____________________________________________________________ (City, State, and ZIP)

DATE (Month, Day, Year)

The undersigned applies for inspection of the processed food products described below in accordance with the regulations of the Secretary of Agriculture (7 CFR 52).  To the best of my knowledge and belief, these containers are not from lots which have been previously inspected by the U.S. Department of Agriculture and are in no way the subject of controversy with any government agency.  The purpose for which inspection is desired is as follows:

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PRODUCT

NUMBER AND KIND OF CONTAINERS

CODES, LABEL, OR OTHER IDENTIFICATION

NAME AND ADDRESS OF PACKER (Include City, State, and ZIP)

REMARKS

APPLICANT

ADDRESS OF APPLICANT (Include Street and Number or RFD Number, City, State, and ZIP)

E-mail Address:

NAME AND TITLE OF REQUESTOR

SIGNATURE OF REQUESTOR