AMS-15 Organic Exemption Request Form

d Organic Exemption Request Form							OMB No. 0581-0093
Persons that produce and market only products eligible to be labeled as “100 percent organic” may request exemption from assessment under research and promotion programs. The information on this form is required to make a determination concerning a person’s eligibility for exemption.
Type of Operation:  Handler  Importer
Please complete the following:
Company name:						Phone:
Street address:						Fax:
City/State/Zip code:						E-mail (optional):
In order to be exempt, the above-named company must meet all of the following (please check):
  	Operates under an approved organic system plan authorized by the National Organic Program (NOP) (7 CFR Part 205) Handles or imports only products eligible for a 100% organic label under the NOP Is not a split operation as defined by the Organic Foods Production Act of 1990
Please list all commodities handled or imported (Use continuation sheet if necessary):
Eligible to be labeled as Commodity 100% Organic? __________________________ Y  N  __________________________ Y  N  __________________________ Y  N 					Eligible to be labeled as Commodity 100% Organic? __________________________ Y  N  __________________________ Y  N  __________________________ Y  N 
		A copy of this company’s organic farm or organic handling operation certificate provided by a USDA-accredited certifying agent must be attached. Importers should attach a copy of this certificate from each person from whom they receive products. (Boards that do not assess importers may delete the second sentence.)
Certification Statement I certify that, at the signing of this statement and for the signed date, the above is true. _______________________________________ ___________________________________ ________________ Signature Title Date
Please return this form to:				Honey Packers and Importers Board Street City, State, Zip
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 0581-0093. The time required to complete this information collection is estimated to average 30 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, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (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 USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, DC 20250-9410, or call 202-720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.

AMS-15 (12-04)

OMB No. 0581-0093

If you need more space to list commodities, please use this sheet.

Continuation Sheet for AMS-15

Organic Exemption Request Form

Honey Packers and Importers Board

Company Name: __________________________________________

In order to be exempt, the above-named company must meet all of the following (please check):

  

Operates under an approved organic system plan authorized by the National Organic Program (NOP) (7 CFR Part 205) Handles or imports only products eligible for a 100% organic label under the NOP Is not a split operation as defined by the Organic Foods Production Act of 1990

Please list all commodities handled or imported

Eligible to be labeled as

Commodity 100% Organic?

__________________________ Y  N 

__________________________ Y  N 

__________________________ Y  N 

__________________________ Y  N 

__________________________ Y  N 

__________________________ Y  N 

Eligible to be labeled as

Commodity 100% Organic?

__________________________ Y  N 

__________________________ Y  N 

__________________________ Y  N 

__________________________ Y  N 

__________________________ Y  N 

__________________________ Y  N 