No Form number OR/CA Potatoes--Shippers Application for Waiver of Inspe

OMB # 0581-0178

OREGON-CALIFORNIA POTATO COMMlTIEE
Marketing Order No. 947
700 NE MULTNOMAH, SUITE 460
PORTLAND, OREGON 97232
Phone: 503-731-3300
SHIPPERS APPLICATION FOR WAIVER OF INSPECTION PRIVILEGE
I request permission to ship potatoes under a Waiver of Inspection Privilege established by the Oregon-California Potato
Committee. I agree to furnish to the Committee all information required on all shipments made under this Waiver of
Inspection Privilege. The information will include but not be limited to the following:

1.
2.
3.
4.
5.
6.

Quantity of potatoes shipped in hundredweight;
How potatoes are shipped (if rail, car number; if truck, license number);
Consignee's name and address;
Brands on containers;
Grade marks - container sizes and type;
Variety of potatoes and quantities of each if different.

All the above information, as well as any other information required by the Committee, will be sent daily to the Committee.

_

I further agree to pay to the Committee an assessment of
per hundredweight on each hundredweight shipped. This
assessment will be paid in addition to all other assessments and fees due and payable on each hundredweight of potatoes.
I understand that failure to meet any of the foregoing requirements will result in the immediate cancellation of this Waiver
of Inspection Privilege.
I certify to the Oregon-California Potato Committee and the Secretary of Agriculture that any shipments made pursuant to
the Waiver of Inspection Privilege will be made in accordance with the current marketing order regulations. I have read
these regulations and I make this application with full knowledge thereof.

Firm Name
Address
City, State, Zip
PhoneIFAX
Signature

Permission is herby granted that above shipper to ship potatoes under a Waiver of Inspection Privilege Certificate, as
defined in the regulations at the time of shipment.

Manager

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 nwnber. The valid OMB control number for this information collection is 0581-0178. The time
required to complete this information collection is estimated to average 3 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,
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. (12/06)