CDAC-3 CA Dates-Application to be Placed on List of Approved Da

CDAC Fonn #3

Send original and one copy to:

California

Date Administrative

Committee

P.O.Box 1736, India, CA 92202-1736
Facsimile: 760.347.6374

Application

to be Placed on the Ust of Approved DateProduct Manufacturers

(Section 98757 and 987.157) approved for OMBlKJ581.{)178

Application is made herewith to be placed on the CDAC list of approved date product manufacturers for the purpose of using, or if not
a handler of dates, acquiring and using, restricted and other marketable dates in the manufacture of products in which the dates lose
their whole or pitted form.
In consideration of approval of this application, undersigned agrees that all dates obtained for manufacturing into products win be
used for that purpose. None will be resold or disposed of as whole or pitted dates, and within 24 (twenty-four) hours of each
completion of disposition of a lot of dates, a report of such will be made to the Committee by filing CDAC form number 8. In addition,
at the end of each crop year, but no later than October 31, an annual report of operations will be filed on CDAC form number 4.
Undersigned states that dates will be used to manufacture the following products:

The quantity of dates to be used for the twelve months, October through September, is estimated to be
pounds, of the
variety (ies).
All manufacturing of dates will occur at (plant location):

I hereby certify to the U.S. Department of Agriculture and the California Date Administrative Committee that the information submitted
herein is complete and correct and that the above agreement as to usage and reporting is accepted.
Firm/Applicant:

By:

Address:

Title:

City:

State:

Date:

Zip:

Approved subject to future revocation by the California Date Administrative Committee for cause.

California Date Administrative Committee
By:

Date:

Your signature certifies that you have the authority to take such action and will submit supplementary
information provided in this ballot is required to determine voter eligibility and vote of potato producers.
than $10,000 or imprisonment
of not more than fIVe (5) years, or both (18 U.S.C. 1001).

evidence of such authority at the request of an agent of the Secretary of Agriculture.
The
Falsification of information on this government document may result in a fine of not more

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 OMS control number for this infonnation collection is 0581'{)178.
The time required to complete this infonnation collection is estimated to average 12 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 inlonnation.
The U.S. Department of Agricullure (USDA) prohibits cliscrimination in all its programs and activities on the basis c:I race, color, national origin, age, disability, and where applicable, sex, marital
status, familial status, parental status, religion, sexual orientation, genetic infonnation,
political beliefs, reprisaL or because all or part c:I an individuars incane is derived from any pubic
assistance program (Not an 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 TOO).
To file a complaint of discrimination,
write to USDA, Director, Office of Civil Rights,
720-6382
(TDD). USDA is an equal opportunity provider and employer.

1400 Independence

Avenue,

S.w.,

WashingtDn,

D.C. 20250-9410,

or call (800)

795-3272

(voice) or (202)