REPRODUCE LOCALLY. Include form number and edition date on all
reproductions.
OMB APPROVED - NO.
0581-0123
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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, |
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TO: Processed Products
Branch
Fruit and Vegetable Programs _____________________________________________________________
(City, State, and ZIP) |
DATE (Month, Day, Year) |
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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 |
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CODES, LABEL, OR OTHER
IDENTIFICATION |
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NAME AND ADDRESS OF PACKER (Include
City, State, and ZIP) |
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REMARKS |
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APPLICANT |
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ADDRESS OF APPLICANT (Include
Street and Number or RFD Number, City, State, and ZIP) E-mail Address: |
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NAME AND TITLE OF REQUESTOR |
SIGNATURE OF REQUESTOR |
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FV-159
(07-04) (Previous editions are to be
destroyed)