WA-302 Examination Report

Form Approved - OMB No. 0560-0120
1. CHECK ONE:

(See Page 2 for Nondiscriminationy, Privacy Act and Public Burden Statements)
U.S. DEPARTMENT OF AGRICULTURE
WA-302
Farm Service Agency
(11-01-04)

ORIGINAL
SUBSEQUENT

AMENDMENT

EXAMINATION REPORT
2. CODE NO.

3. LICENSE NO.

4. AMENDMENT

6. CAPACITY

5. DATE OF LICENSE (MM-DD-YYYY)

8. NAME OF WAREHOUSE OPERATOR

12. MAILING ADDRESS OF HEADQUARTERS OFFICE (Zip Code)
(Include street address for express delivery)

9. NAME OF WAREHOUSE

13. LOCATION OF WAREHOUSE (City, County, Parish and State)

10. MAILING ADDRESS OF WAREHOUSE (Including Zip Code)

14A. TELEPHONE NO.
(Include Area Code)

11. PRINCIPAL PLACE OF BUSINESS

14C. EMAIL ADDRESS (If Applicable)

7. TYPE OF AGREEMENT

CHECK (if changed, note)

14B. FAX NO.
(Include Area Code)

15. INDIVIDUAL IN CHARGE (HOME ADDRESS AND HOME TELEPHONE NUMBER (Include Area Code))

16. TYPE OF BUSINESS ENTITY:
CORPORATION

LLC

INDIVIDUAL

PARTNERSHIP

17. CORPORATION (Original Examination Only)
A. CHARTER EXPIRES (Date)
(MM-DD-YYYY)

B. FOREIGN CORPORATION PERMIT ISSUED BY

C. PERMIT EXPIRES (Date) (MM-DD-YYYY)

State of
D. AUTHORIZED TITLES FOR SIGNATURES

E. AUTHORIZED BY:

BY LAWS

RESOLUTION

18. CORPORATE OFFICERS
A. PRESIDENT

B. VICE PRESIDENT

C. VICE PRESIDENT

D. VICE PRESIDENT

E. TREASURER

F. SECRETARY

A. TYPE OF PARTNERSHIP (General, limited, etc.)

19. PARTNERSHIP (List names below if not shown above)
B.

C.

D.

E.

F.

G.

20. LIMITED LIABILITY COMPANY
A. OPERATING AGREEMENT
C. AUTHORIZED TITLES FOR SIGNATURES (If applicable)

B. ARTICLES OF ORGANIZATION
D. AUTHORIZED BY
Operating Agreement

Articles of Organization

21. INDIVIDUAL
A. NAME

B. HOME ADDRESS & HOME TELEPHONE NO. (Include Area Code)

22. NAMES OF INDIVIDUALS AUTHORIZED TO SIGN WAREHOUSE RECEIPT (Federally licensed houses only)

Page 2

WA-302 (11-01-04)
23. OUTSTANDING LICENSES ISSUED TO INSPECTORS AND WEIGHERS (Federally licensed houses only)
B. SERVICE
PERFORMED

A. NAME OF LICENSEE

C. LICENSE NO.

D. WHERE POSTED

CHECK (if changed, note)

24. IS ALL STORAGE SPACE COVERED BY THIS REPORT INCLUDED OR TO BE INCLUDED UNDER LICENSE? IF "NO", EXPLAIN ON
FORM WA-101.
YES
NO
25. IS WAREHOUSE OPEN AT LEAST 6 HOURS EACH BUSINESS DAY? IF "NO", EXPLAIN ON FORM WA-101 THE PROVISIONS MADE TO
RECEIVE, DELIVER AND SETTLE ON AGRICULTURAL PRODUCTS.
YES

NO

26. NAME OF ELECTRONIC WAREHOUSE RECEIPT PROVIDER.

27. DOES WAREHOUSE OPERATOR HAVE ANY TYPE OF AGREEMENT WITH A FIELD WAREHOUSE COMPANY? IF "YES", HAS THIS BEEN
CLEARED WITH USDA? IF "NO", FURNISH COPY TO EXAMINER/KCCO.
YES
28A. EXAMINER SIGNATURE

NOTE:

NO
28B. DATE (MM-DD-YYYY)

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a) and the Paperwork Reduction Act of 1995, as
amended. The authority for requesting the following information is 7 CFR Parts 735 and 1421.5554. Furnishing the requested information is
voluntary and no penalty will be imposed for failure to respond. However, a response is required in order to be considered for a warehouse license
(7 U. S. C. 242) and the decision as to the applicant's eligibility for a license must be made in part on the basis of the information provided. This
information will not be disclosed outside of the U.S. Department of Agriculture except as required by law to the Department of Justice and the
Department of Treasury. This information may be provided to other agencies, IRS, Department of Justice, or other State and Federal law
enforcement agencies, and in response to a court magistrate or administrative tribunal. The provisions of criminal and civil fraud statutes, including
18 U.S.C. 286, 287, 371, 641, 651, 1001; 15 U.S.C. 3729, may be applicable to the information provided.
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 0560-0120. 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. RETURN
THIS COMPLETED FORM TO KANSAS CITY COMMODITY OFFICE, WAREHOUSE LICENSE AND EXAMINATION DIVISION.

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, D.C. 20250-9410 or call (202) 720-5964
(voice or TDD). USDA is an equal opportunity provider and employer.