No Form number Oregon/California Seed Potatoes Certificate of Privilege

OMB No. 0581-0178

OREGON-CALIFORNIA POTATO COMMITTEE
Marketing Order No. 947
700 NE MULTNOMAH, SUITE 460
PORTLAND, OREGON 97232
Phone: 503-731-3300
HANDLERS APPLICATION FOR CERTIFICATE OF PRIVILEGE
FOR SHIPMENT OF CERTIFIED SEED
Application is herby made for the issuance of a Certificate of Privilege for the 20xx-20xx marketing
year to permit me to make shipments of certified seed as specified in Handling Regulation §947.340.
In consideration ofthe Committee granting this Certificate, I agree to the following:
1. That I will report to the Committee all shipments of certified seed outside the district where
grown.
I certify to the Oregon-California Potato Committee and the Secretary of Agriculture that any
shipments made pursuant to this Certificate of Privilege will be made in accordance with the
regulations of the Oregon-California Potato Committee.

Handler (please Print)

Authorized Representative's Signature

Address

City, State, Zip

Telephone Number

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 infonnation unless it displays a valid OMB control number. The valid OMB control number for this infonnation collection
is 0581-0178. The time required to complete this infonnation collection is estimated to average 5 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 infonnation.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis ofrace, 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.
(1107)