No Form number Colorado Potatoes (Area III) (Chipping Potatoes)

OMB #0581-0178
Federal Marketing Order 948
State of Colorado MO Docket A-4

No.

COLORADO POTATO ADMINISTRATIVE COMMITTEE
NORTHERN COLORADO OFFICE AREA m
P.O. BOX 1774
GREELEY, CO 80632
Phone (970) 352-5231 FAX (970) 304-0861

APPLICATION FOR CERTIFICATE OF PRIVILEGE
FOR SPECIAL PURPOSE SHIPMENT REPORTS
CERTIFICATE OF PRIVILEGE FOR SPECIALPURPOSE REPORTS are required for the
shipment of potatoes for other than fresh market purposes. CHECK THE INTENDEDUSE FOR
WHICH YOURPOTATOESWILL BE SHIPPED.
_CHIPPING
_OTHER

_CANNING

_FLAKE

_SHOESTRING

_CHARITY
)

(please specify

It is understood and agreed to by me, the undersigned applicant, that all potatoes granted a
Certificate of Privilege for Special Purpose Shipments by virtue of this application and
corresponding Special Purpose Shipment Reports must be used for the purpose stated in this
application and any deviation or infringement of this privilege which shall become known to me will
be reported to the Area m Committee promptly. Further, that I wiII not knowingly seDor cause to
be sold potatoes which have been granted a Certificate of Privilege and are to be used in violation of
said Certificate. I am aware that when Special Purpose Shipment Reports are used for OTHER
THAN POTATOES FOR CHIPPING, the RECEIVER must return a copy of the report to the Potato
Administrative Committee within 15 days.
The Certificate of Privilege/Special Purpose Shipment Reports granted subject to this Application
shall be numbered consecutively from
to
inclusive. Allor any part of
said Reports not duly executed may be recalled or revoked at the discretion of the Committee and
when violation of said application and reports are in evidence. It is agreed that the Committee will
be notified of any shipments rejected by receivers of processed potatoes.
In addition to the penalties provided in § 608(c)(14) of the Agricultural Marketing Agreement Act of 1937,
as amended, other Federal statutes provide, in substance, that any person who knowingly makes a false or
fraudulent statement for the purpose of influencing the actions of a government agency shaD be guilty of a
felony, and upon conviction shaD be subject to a '-me or imprisonment, or both.
Approved by Area HI

Company Name:

Date:

Business Address:

Additional Forms Issued:

City, State, Zip:
Mailing Address:
Authorized Signature:

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communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600
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Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TOO). USDA is an equal opportunity provider and
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