FV-211 Application for License rev.

OMB Approved - 0581-0031

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

For questions call (800) 495-7222 ext 1
PACA Website:
http://www.ams.usda.gov/paca

APPLICATION FOR LICENSE
(Under the Perishable Agricultural Commodities Act, 1930)

The information requested on this form is required under the Perishable Agricultural Commodities Act (7 CFR 46.4) for the issuance of a license. The information contained in this form will be used by Federal, State,
local, or foreign agencies when relevant to civil, criminal, or regulatory investigations or procedures. Failure to provide the information required will result in delay or suspension of the processing of this form.

ALL QUESTIONS MUST BE ANSWERED
1a. Name of Business (Full Legal Name of Business registered under EIN)

1b. If Sole Proprieter, enter Owner’s Full Name

3. Web Site

2. Federal Employer Identification Number (EIN)

4a. Physical Business Address (Post Office Box NOT ACCEPTABLE)

Street Address
City

State

Telephone Number (With Area Code)
4b. Mailing Address

Zip Code+4

Fax Number (With Area Code)

E-Mail Address

(Mark an “X” here if same as Business Address):

Street Address (Post Office Box Number)
City

Attention:
State

Zip Code+4

5a. Does the business have any branch locations other than your physical business address?

Yes

How many? ______

No
5b. Does the business have additional trade names?

Yes

No

5c. Please list Trade Names and/or Branch Locations Below. (Attach a separate page for additional entries)

Trade Name

6a. Legal Structure (see page 4 for explanations)
(CHECK ONE BOX ONLY)

Sole Proprieter

City

6b. Complete only if you checked Corporation or LLC

State

Limited Partnership
Corporation (see 6b)
Estate
Partnership
Trust
Limited Liability Company (LLC) (see 6b and 6c)
Limited Liability Partnership (LLP)

State

Date of Incorporation/Organization

Month

Day

Year

6c. Complete only if you checked LLC

Articles of Organization is included with application
Operating Agreement is included with application
8. Primary Nature of Business: (see page 4 for explanations)
(CHECK ONE BOX ONLY)

Broker

Processor

Retailer

Commission Merchant

Shipper

Fresh

Food Service

Trucker

Grocery
Wholesaler

Frozen

Grower

Wholesaler

Fresh and Frozen

Growers’ Agent

7. Types of Fruits and Vegetables Handled by Applicant
(CHECK ONE BOX ONLY)

FV-211 (12-08)

Page 1 of 4

9. List Principals, Owners, and Stockholders holding more than 10% of stock (REQUIRED)

List below the requested information for Individual Owner, All Partners, Members and/or Managers of LLCs, Officers
(Including Titles), Directors, Trustee, Guardian, and Stockholders holding more than 10 percent of outstanding voting
stock. If any person listed is a minor, furnish the name of His/Her guardian. If any person listed is a trust, furnish the
name of the trustee. If any person listed is an estate, furnish the name of the Executor/Executrix.
(Attach a separate page for additional entries)
Social
Security
Number

Name
Last Name (Print on First Line)
First Name and Middle Initial

Smith
John A.

S

A

Home Address
First Line - Number and Street
Second Line - City, State, and ZIP Code
(Post Office Box NOT ACCEPTABLE)

M

123-45-7890

P

123 Main Street

L

Anytown, DC 12345-7890

Title
(Including
Director)

E

President

Percentage
of Stock or
Ownership

75%

10. Has the applicant or any person listed in Question 9 filed bankruptcy, been discharged as a bankrupt, or been an
officer, director, shareholder, partner, member/manager (LLC), or owner of a firm that has filed bankruptcy or been
discharged as bankrupt?
Yes

No

If Yes, identify the firm or individual (PACA license number, if possible), the name and
address of the firm involved, and details about bankruptcy. Submit a copy of the bankruptcy
petition, schedules, disclosure statements, and all other relevant documentation.
(Attach a separate sheet for additional space)

11. Has any person listed in Question 9 been convicted of a felony in any State or Federal Court?
Yes

No

If Yes, furnish the name, date of birth, and alias (if any), of the individual(s), if any. FOR ALL
CONVICTIONS, provide the name and location of the court, date convicted, nature of the
felony, sentence imposed, where served; if paroled, give date terminated or will terminate.
(Attach a separate sheet for additional space)

12. Has any person currently employed by the applicant been the individual owner, partner, officer, director, or holder
of more than 10 percent of the outstanding voting stock of a firm, association, or corporation, or a member/
manager (LLC) whose PACA license is under suspension; been revoked; found to have committed any flagrant or
repeated violation of the PACA, or against which there is an outstanding unpaid reparation award?
Yes

FV-211 (12-08)

No

If Yes, furnish the full name of the person, name of the firm involved (PACA License number
if possible), and details of such connection, including the dates thereof.
(Attach a separate sheet for additional space)

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13. Is the applicant currently operating at volumes requiring a PACA License? (See Page 4 for Nature of Business explanation)
Yes

No

If Yes, provide the date applicant first met that volume.

Month

SCHEDULE A

Day

Year

(Brokers, Commission Merchants, Food Service, Growers, Grower’s Agent, Processors, Shippers, Truckers,

and Wholesalers)

License Fees
Annual License Fee:........................................................................................... $

550.00

Branch Fee: $200 for each Branch over 9 (Maximum $3450).......................... $__________
$__________ Total Fee per Year
Multiplied by $__________ Number of Years for
License (Maximum 3)
$__________ Total License Fee
Accrued Fees for Previous Operations (No more than 2 years)
Monthly License Fee:.......................................................................................... $

45.83

Monthly Branch Fee: $16.67 for each branch over 9 (Maximum $287.50).........$__________

$__________ Total Fee per Month
Multiplied by $__________ Number of Months
(Maximum 24)
$__________ Total Fees for
Previous Operations
(Total License Fee + Total Fees for Previous Operations) $

SCHEDULE B

Total Amount Due

(Retailers and Grocery Wholesalers only, all others see Schedule A)

100.00

Adminstrative Fee for Initial Application................................................................$

(Retailers
( and Grocery Wholesalers that have been previously licensed are not required to submit additional administrative fees)

PAYMENT

Checks: Make Checks payable to “USDA - AMS”
Credit Cards:
Type of Card
Visa
Mastercard

Amount:
AMEX

Account Number:

Discover

Diners Club

Exp Date:

Card Holder’s Name:
Application must be signed by the Owner, all Partners, all General Partners, the
Trustee, Executor/Executrix, a Member/Manager (LLC), or a Corporate Officer.

RETURN COMPLETED APPLICATION AND FEES TO:
USDA, PACA Branch, National License Center
8700 Centreville Road, Suite 202
Manassas, VA 20110-8411

CERTIFICATION STATEMENT
I (We) certify that the answers given to the foregoing questions are true to the
best of my (our) knowledge. Applicant agrees not to loan or transfer
possession of the license certificate to any person or firm whatsoever.
Signature(s):

Date:

If Paying Fees by Credit Card, Fax Application to:
(703)330-4555
FV-211 (12-08)

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DEFINITIONS AND TERMS
Dealer (includes wholesalers, jobbers, distributors, and growers who market produce grown by others) means any person engaged in the business of buying or selling in wholesale or jobbing quantities, as
defined by the Secretary, any perishable agricultural commodity in interstate or foreign commerce. A person who buys potatoes for canning or processing is a dealer whether the potatoes are purchased
within the state or in interstate or foreign commerce.
Interstate or Foreign Commerce means all transactions involving fresh and frozen fruits and vegetables which move between states, and/or other countries and the U.S.
Wholesale or Jobbing Quantities means aggregate quantities of all types of produce totaling one ton (2,000 pounds) or more in weight in any day shipped, received, or contracted to be shipped or received
Branch or Additional Business Facility means an office or outlet in a location other than that of the principal or main office of a firm, out of which or through which the firm purchases, sells, negotiates
contracts, solicits, or handles consignments, or otherwise contracts in perishable agricultural commodities including seasonal, part-time and full-time operations.

NATURE OF BUSINESS: (See Question 8)

LEGAL STRUCTURES: (See Question 6a)

The following are definitions of the types of dealers, brokers and commission
merchants that are required to have a PACA license.

Individually owned or Sole Proprietorship means one person has complete ownership and is
fully responsible for all activities.

Wholesaler, see Dealer (above)

Corporation is authorized by state law to act as a single entity and is registered with the secretary/
corporation commission of a state. The corporation can have elected officers and directors, an
appointed registered agent and shareholders. Shareholders can be individuals, other corporations,
LLC, partnerships, etc.

Foodservice is a dealer that purchases and sells fresh and/or frozen fruits and vegetables in interstate
or foreign commerce for distribution to restaurants, institutions, convenience stores, etc. These
operations commonly also sell non-subject items as well.
Processor is a dealer that purchases fresh and/or frozen fruits and vegetables in interstate or foreign
commerce for canning or processing or sells product in interstate or foreign commerce that has not had
its kind or character changed (i.e., salad mixes, sliced fruit, vegetables, frozen or packed in ice or
consists of cherries in brine, etc.). However, a processor is not subject if the purchasing and
processing which changes the kind and character are both accomplished within the State where the
produce is grown, even if the processed product is shipped out of the State.
Shipper is a dealer who operates at shipping point and is engaged in the business of purchasing
produce from growers or others and distributing such produce in commerce by resale or other
methods, or who handles such produce on joint account with others.
Trucker is a dealer that purchases and sells fresh and/or frozen fruits and vegetables in interstate or
foreign commerce from its truck not as a retailer.
Retailer is a dealer when it purchases wholesale and jobbing quantities, but is only subject to a PACA
license when the invoice cost of all purchases of produce (including frozen potato products such as
French fries) exceeds $230,000 during a calendar year. In computing dollar volume, all purchases of
fresh and frozen fruits and vegetables are to be counted, without regard to quantity involved in the
transaction or whether the transaction was intrastate, interstate or foreign commerce.
Grocery Wholesaler is a dealer primarily engaged in the full-line wholesale distribution and resale of
grocery and related nonfood items (such as perishable agricultural commodities, dry groceries, general
merchandise, meat, poultry, and seafood, and health and beauty care items) to retailers. This term
does not include persons primarily engaged in the wholesale distribution and resale of perishable
agricultural commodities rather than other grocery and related nonfood items. Specifically, for an
entity to be considered a grocery wholesaler, 50 percent or more of its annual gross sales must be
from the full-line distribution and resale of grocery and related nonfood items, and it cannot have more
than 50 percent of its sales in perishable agricultural commodities. “Full-line” means that an entity
must be supplying the retailer with a wide range of products such as the grocery and related nonfood
items specified.
Broker means any person engaged in the business of negotiating sales and purchases of any
perishable agricultural commodity in interstate or foreign commerce for or on behalf of the vendor or
the purchaser, respectively. The 2000 pound quantity limitations do not apply to brokers. They are
subject to PACA licensing with their first interstate or foreign commerce transaction. It is common in
the industry to have fresh produce brokers and frozen produce brokers. Frozen produce brokers who
negotiate contracts for frozen commodities exclusively for the vendor and the invoice value of the
vendor’s product does not exceed $230,000 in a calendar year are not subject; however, frozen
produce brokers that are negotiating contracts for the buyer are subject no matter the invoice price.
Commission Merchant means any person engaged in the business of receiving in interstate or foreign
commerce any perishable agricultural commodity for sale, on commission, or for or on behalf of
another. For example, a person who receives a truckload of tomatoes; sells the product for a grower;
charges a commission; and remits the net proceeds to the grower. The 2000 pound quantity
limitations do not apply.
Grower is a business that grows its own fruits and vegetables and is not required to be licensed.
However, a grower can be licensed on a voluntary basis and must comply with the PACA law while
licensed.
Growers’ Agent means any person operating at shipping point who sells or distributes produce in
commerce for or on behalf of growers or others and whose operation may include the planting,
harvesting, grading, packing, and furnishing containers, supplies, or other services. The 2000 pound
quantity limitations do not apply, because this type of business is considered a type of commission
merchant.

FV-211 (12-08)

Limited Liability Company or “LLC” is a form of a legal entity where the state law provides for
a firm to be treated as a partnership for tax purposes, while receiving the benefits from personal
liability usually associated with a corporation. LLC’s are also registered with the secretary/
corporation commission of a state. NOTE: LLC’s are required to submit a copy of their Articles
of Organization and Written Operating Agreement with the application
Partnership is a voluntary contract between two or more persons who agree to carry on any
business or venture together, upon the terms of mutual participation in its profits and losses, this
can be a verbal or written agreement. NOTE: Any change in partners will require a new
license.
Limited Partnership is a partnership consisting of one or more general partners, jointly and
severally responsible as ordinary partners, and by whom the business is conducted, and one or
more special (limited) partners, contributing in cash payments a specific sum as capital, and who
are not liable for the debts of the partnership beyond the funds contributed. Limited partnerships
are required to be registered with the secretary/corporation commission of a state. NOTE: A
change in any general partner will require a new license.
Limited Liability Partnership or “LLP” is a form of a legal entity where the state law provides
for a firm to be treated as a partnership for tax purposes, while its individual partners receive
protection against personal liability of certain partnership liabilities. LLP’s are also registered with
the secretary/corporation commission of a state.
Association is commonly referred to as a Cooperative Marketing Association; a body of persons
united and sometimes acting together without a charter in the pursuit of some common enterprise;
basically a large partnership, but differs from a partnership in that it is not bound by the acts of the
individual partners, but only by those of its manager(s) or trustee(s). NOTE: While PACA
exempts growers from the licensing requirements, cooperative marketing associations must be
licensed, even if the produce being handled is that solely of its members.
Trust is a right of property, real or personal, held by one party for the benefit of another; any
arrangement whereby property is transferred with intention that it will be administered by a trustee
for another’s benefit.
Estate is the property, real or personal, which a person has a right or interest and descends by law
to heirs at that person’s death.
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
ontrol number. The valid OMB control number for this information collection is 0581-0031. 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.

PENALTY:
Any person who operates without a valid and
effective license shall be liable to a penalty of not
more than $1,200 for each such offense and not more
than $350 for each day it continues.
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