No Form number ID/E.OR Potato Cmte. Application for Consideration of Ap

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OMS No. 0581-0178

Mail to:
P.O. Box 2192

IDAHO-EASTERNOREGON POTATO COMMITTEE
Administering
Federal Marketing Order No. 945
1775 E. 17th Street
Idaho Falls, Idaho 83403
Phone: (208) 529-8057
Fax: (208) 529-8057
Date:

POTATO COMMITTEE APPLICATION FORM
FOR CONSIDERATION OF APPROVAL AS A CANNER, FREEZER, OR
OTHER PROCESSOR OR PREPEELER OF POTATO PRODUCTS
FOR SPECIAL PURPOSE SHIPMENT REPORTS
IDAHO-EASTERN OREGON POTATO COMMITTEE

TO:
FROM:

(Applicant's Name)
lIWe

hereby
(The Above Named Applicant)
apply to the Idaho-Eastern Oregon Potato Committee (Committee) for approval as a "RECEIVER"of
potatoes under the Committee's Special Purpose Permit for the purpose of
(Canning, Freezing, Other Processing, or Prepeeling---List One..)
lIWehereby certify to the Committee and the Secretary of Agriculture, USDA(Secretary) that
potatoes received from the Idaho-Eastern Oregon potato production area for processing, will be
used for the purpose stated above, and will not be placed in fresh market channels.
lIWeagree to report on shipments received as the Committee may require.
The undersigned certifies to the Committee and the Secretary of Agriculture that potatoes
received will be used in accordance with current Marketing Order Regulations for use only
for the purpose stated. I realize that the making of a false statement, knowing it to be false,
is a violation of Title 18, Section 1001, of the United States Code, which upon conviction,
provides for a fine or imprisonment, or both.
NAME OF COMPANY
ADDRESS
(STREET OR BOX #)
AUTHORIZED

CITY

STA TE

ZIP

SIGNATURE

**If you list "other processing" also show the specific use, as "other processing" is defined.
According to the Paperworl< Reduction Act of 1995, en egency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it
displays a valid OM8 conlrol number. The valid OM8 conlrol number for this information collection is 0581.{J178. The time required to complete this information collection is
estimated to average 9 minutes per response, including /he time for reviewing inslructions, searching existing data sources, gathering and maintaining /he data needed, and
completing and reviewing /he collection of information.
The U.S. Department of A9riculture (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 filea complaintof discrimination,writeto USDA,Director,Officeof CivilRights, 1400Independence Avenue, S.W., Washington,D.C.20250-9410,or call (BOO)795-3272
(voice) or (202) 72JNJ382 (TDD). USDA is an equal opportunity provider and employer.