No Form number IDaho/E. Oregon Potatoes Application for Certificate of

IDAHO-EASTERN

OREGON POTATO COMMITTEE
OMB No. 0581-01
Administering
Federal Marketing Order No. 945
1775 E. 17th Street
Certificate No.:
Effective Date:
Idaho Falls, Idaho 83403
Phone: (208) 529-8057
Expiration Date:
Fax: (208) 529-8057

Mail to:
P.O. Box 2192
Idaho Falls, Idaho 83403

78

APPLICATION FOR CERTIFICATE OF PRIVILEGE
FOR SPECIAL PURPOSE SHIPMENT REPORTS
CERTIFICATE
OF PRMLEGEFORSPECIALPURPOSEREPORTSare required for the shipment of potatoes for
other than fresh market purposes.
CHECK THE INTENDED USE FOR WHICH YOUR POTA TOES WILL BE SHIPPED.

CHIPPING

D

CANNING

FLAKE
D

D

SHOESTRING

CHARITY OTHER

D

D

Slaipment
Destination:

CWT

D

to be slaipped:

SlaipmHl Date:

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 Potato Committee promptly. Further, that I will not knowingly sell or 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, the RECEIVER must return a copy of the report to the
Potato Committee within 15 days.
In addition to the penalties provided in § 608(c)(14) of the Agricultural Marketing Agreement Act of 1937, as amended,
Title 18, Section 1001, of the United States Code, provides that any person who knowingly makes a false or fraudulent
statement for the purpose of influencing the actions of a government agency shall, upon conviction, be subject to a fine
or imprisonment, or both.

Appro"ed lay Potato Committee

Address

Date

City, State, aad Zip Code

I
Autlaorized Signature
According to the Paperwork Reduction Act of 1995, an agency may not conduct a sponsor, and a person is not required to respond to e collection of information unless it displays a valid OMS
control number. The valid OMS control number fa this information collection is 0581'()178. The time required to complete this information collection is estimated to average 10 minutes per
response, including the time for reviewing instructions, seerching existing data SOIJ1Ce8,gathering and maintaining the data needed, and completing and reviewing the collection of information.
The U.S. Department of Agriculture (USDA) prohibi/$ discrimination in all i/$ programs and activities on the basis of mce, ooIcr, national origin, age, disability, and where applicable, sex, marital
status, familial status, parental status, religion, sexual orientation, genetic information, poIilical beliefs, reprisal, or because all or pari of an individuaFs income is derived from any public
assistance f"OfJrem (Not all prohibited bases apply to ell progmms.) Persons with disabilities who requite altemetive means for communication of program information (Braille, Ietge print,
audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2(j()() (voice and TDD).
To file a complaint of discrimination, write to USDA, Directa, Office of Civil Rights, 1400 Independence

6382 (WD). USDAis an equalopporlunityproviderand employer.

Avenua, S. W., Washington, D.C. 20250-9410, or call (BOO)795-3272 (voice) a (202) 720-