No Form number South Texas Onion Committee Certificate of Privilege

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OMBOS81-0178

20XX-20XX

CERTlFICA7E OF PRIVILEGE #

I. THE UNDERSIGNED. HEREBYCERTIFYTO THE SECRETARYOF AGRICULTUREAND TO THE
SOUTH TEXAS ONION COMMITTEETHAT I HAVE READ. FULLY UNDERSTAND. AND WILL
COMPLY WITH THE FOREGOINGRULES WHICH GOVERNTHE HANDLINGOF ONIONS WHICH
FAIL TO MEET THE SOUTH TEXAS ONION RULES AND REGULATIONS. I FURTHER
UNDERSTAND THAT NON COMPLIANCEIS A VIOLATIONOF THE AGRICULTURALMARKETING
AGREEMENTACT AND SUBJECT TO A FINEOF UP TO $1.100 FOR EACHVIOLATION.
BY:
nt Name

'ate

'Ignature

TITLE:

FIRM:
MAILING ADDRESS:

FAX:

PHONE:
Person in Charge of SPEOAL PURPOSE FORMS:
PURPOSE OF SHIPMENlS (Check):

D
D
D

Canning or Freezing
Relief or Charity
Other:

WHERE WILL SHIPMENTS ORIGINATE?
PLEASE UST B8...0W THE NAMES AND ADDRESSES OF CONSIGNEES YOU PLAN m SEND SPECIAL
PURPOSE ONIONS THIS YEAR:
I\lame

"Name

Name

"Name

I\lame

"Name

*Note: Before sending special purpose onions to canners and/or freezers that have not been
FOR OFACE

USE ONLY

APPROVED BY:

DATED:

OMB 0581-0178

Note: The following statements are made bt accordance with the Privacy Act of 1974 (S U.S.C. SS2a) and the Paperwork Reduction Act of 1995. The
authority for requesting this information to be supplied on this form is the Agricultural Marketing Agreement Act oft937, Sea. 1-19, 48 Stat. 31, as
amended, (7 U.S.C. 601-674). Fumishlng the requesteclinformation is necessary for the administration of the marketing order program.
Accordbtg 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 OMB control number for this information collection is 0581-0178. The time
requIred to complete this information collection is estimated to average S mbtutes per response, btclndbtg the time for reviewing instructions,
searchlng e:dstlng data sources, gatherbtg and maintaining the data needed, and completing and revlewing the collection ofinformatloo.
The u.s. Deparlment of Agriculture (USDA) prohibits discrimb1ation bt 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 btcome is derived from any public assistance program (Not all prohibited bases apply to all
programs.) Persons with disabillties who requlre altemative means for communication of program information (BraUIe, large print, audiotape, etc.)
should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To me a complabtt of discrimb1ation, write to USDA. Director, OftIce of
CivO Rights, 1400 Independence Avenue, S.W., Washlngton, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (fDD). USDA is an
equal opportunity provider and employer.