No Form number CO. Potatoes (Area II) Certificate of Privilege Special

No.

COLORADO POTATO ADMINISTRATIVE COMMITTEE
OMS # 0581-0178
SAN LUIS VALLEY OFFICE AREA II
Federal Marketing Order 948
P.O. BOX 348
State of Colorado MO Docket A-4
MONTE VISTA, CO 81144
Phone (719) 852-3322 FAX (719) 852-4684

APPLICATION FOR CERTIFICATE OF PRIVILEGE
FOR SPECIAL PURPOSE SHIPMENT REPORTS
CERTIFICATEOF PRIVILEGEFOR SPECIALPURPOSE REPORTS are required for the shipment of
potatoes for other than fresh market purposes. PLEASE CHECK THE INTENDED USE FOR WHICH
YOUR POTATOES WILL BE SHIPPED.
CHIPPING

D

CANNING

D

FLAKE

D

SHOESTRING

D

CHARITY

D

OTHER

D

If other, please specify

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 Colorado Potato
Administrative Committee Area II (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 Committee office within 15 days.

-

The Certificate of Privilege/Special Purpose Shipment Reports granted subject to this Application shall be
numbered consecutively from
to
inclusive. All or any part of said
Reports not duly executed may be recalled or revoked at the discretion of the Committee and when
violation of said application and reports are in evidence. It is agreed that the Committee will be notified of
any shipments rejected by receivers of processed potatoes.
In addition to the penalties provided in § 608(c)(14) ofthe Agricultural Marketing Agreement Act of 1937,
as amended, other Federal statutes provide, in substance, that any person who knowingly makes a false
or fraudulent statement for the purpose of influencing the actions of a government agency shall be guilty
of a felony, and upon conviction shall be subject to a fine or imprisonment, or both.
Company Name
Approved by Area II
Date

Business (or Street) Address

City, State, and Zip Code
Mailing Address (if other than above)
Authorized Signature

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
information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0581-0178. The time

of

required to complete this information collection is estimated to average 9 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 USDA, Director, Office of Civil Rights, 1400
Independence Avenue, SW, Washington, DC 20250-9410 or call (BOO) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity
provider and employer.