F/H Form D Hazelnuts--Application to be Listed as an Accepted User

F/H Fonn D
OMB CONT.NO.
0581-0178

HAZELNUT MARKETING BOARD
21595-A Dolores Way N.E.
Aurora, OR 97002-9738

APPLICATION TO BE LISTED AS AN ACCEPTED USER OF INEDIBLE HAZELNUTS
AND HAZELNUT WASTE
To: Hazelnut Marketing Board,
Application is made herewith to be listed by the Hazelnut Board as an accepted user of inedible hazelnuts and hazelnut
waste and for approval of the use of such material in the outlet(s) checked below:
.crushingfor hazelnut oil
mixing into feed
feeding directly to livestock or poultry
This will occur at (give location) :
(street)

(city)

In consideration of the approval of this application, undersigned agrees that all hazelnut material acquired from hazelnut
handlers or growers will be used only for the purposes indicated, that none will be disposed of for human consumption
and that Board employees may enter applicant's premises at any reasonable time to observe the storage or disposition of
the material and to examine and audit applicant's records of his transactions. Undersigned also agrees to obtain from each
handler an executed F/H Fonn
on each lot of material received and, upon crushing, mixing or feeding the
hazelnuts, to execute part (b) of the fonn and mail it to the Board.
Undersigned hereby certifies to the U.S. Department of Agriculture and to the Board that the information supplied herein
is complete and correct and that the above agreement as to usage and reporting is accepted.
Note: The making of any false statement or representation on this form, knowing it to be false, is a violation of Title 18,
Section 1001, United States Code, which provides for the penalty of a fine of $ 10,000 or imprisonment of not more than
five years, or both.
Date

,20

User Finn
Address
By

Title

Application is hereby approved, subject to revocation for cause:
Date

Hazelnut Marketing Board
By

Title

OMB requires that the following statement be shown: "No approval can be obtained allowing a user of inedible hazelnuts and waste to make
acquisition from a handler until the application form is received (7 U.S.C. 608 (d), 7 C.F.R. 984.64 and 7 C.F.R. 984.464)."
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 -0178. The time required to complete this
information collection is estimated to average 20 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,
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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 (I'DD). USDA is
an equal opportunity provider and employer.