FTC-108 Florida Tomatoes Application for Certificate of Privileg

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OMS #0581-0178

20XX-20XX
APPLICATIONFOR CERTIFICATEOF PRIVILEGE
Information given in this form is for the use of the Florida Tomato Committee, acting
under the authority of the Secretary of Agriculture of the United States.
Section 966.54 of the Order requires that handlers desiring to make shipments of
tomatoes for relief, charity, processing, or such other purposes, which may be specified
by the Florida Tomato Committee, with the approval of the Secretary of Agriculture,
shall prior to making such shipment, apply to the Florida Tomato Committee for a
Certificate of Privilege. The purpose of such certificate is to safeguard against the entry
of such tomatoes into the trade channels other than those for which this Certificate of
Privilege is granted. REPORTS ON EACH SHIPMENT MUST BE MADE TO THE
FLORIDA TOMATO COMMITTEE ON THE SHIPPING DATE ON FORM FTC-110.
RECEIVERS MUST RETURN THE BLUE COpy TO THE FLORIDA TOMATO
COMMITTEE WITHIN TEN DAYS AFTER RECEIPT. FAIL RE TO DO SO MAY
RESULT IN THE REVOCATION OF YOUR CERTIFICATE OF PRIVILEGE.
Name of Applicant
Address
Purpose of shipment for which Certificate of Privilege is requested
Is the applicant registered as a tomato handler with the Florida Tomato Committee?
Yes
No
. If so, please give Registration No.
To the best of my knowledge and belief, all statements contained in this application are
true, correct and complete.
Date

Name of Firm

Telephone Number

Signature of Applicant

Fax Number

E-mail address

DO NOT WRITE BELOW THIS LINE
Approved

Disapproved

Date

Signature of Manager of Committee
FTC Form 108

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Note: The following statements are made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a) 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 of 1937, Sees. 1-19,48 Stat. 31, as amended, (7 U.S.C. 601-674).
Furnishing the requested information is necessary for the administration of the marketing order program.
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
OMB control number for this information collection is 0581-0178. The time required to complete this
information collection is estimated to average 5 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.