Form No Form number No Form number CO. Potatoes (Area III) Spec. Purpose (consideration of

u............

COLORADOPOTATOADMINISTRATIVECOMMITTEE
NORTHERNCOLORADOOFFICE AREA III
P.O. Box 1774
Greeley, CO 80632
Phone (970) 352-5231 FAX(970) 304-0861

OMB # 0581-0178
Federal

Marketing

POTATO ADMINISTRATIVE COMMITTEE APPLICATION FORM
FOR CONSIDERATION OF APPROVAL AS A CANNER, FREEZER, OR
OTHER PROCESSOR OR PREPEELER OF POTATO PRODUCTS
FOR SPECIAL PURPOSE SHIPMENT REPORTS
TO:

Colorado Potato AdministrativeCommittee
Northern Colorado OfficeArea III
P. O. Box 1774
Greeley, CO 80632

FROM:
(Applicant's Name)

I/We
(The Above Named Applicant)
Hereby apply to the Colorado Potato AdministrativeCommittee (Committee)for approval as a
"RECEIVER" of potatoes under the Committee's Special Purpose Permit forthe purpose of
(Canning, Freezing, Other Processing, or Prepeeling-Ust One-)
I/We hereby certifyto the Committee, the Commissioner of Agriculturefor the State of Colorado
(Commissioner), and the Secretary of Agriculture,USDA(Secretary) that potatoes received from
the Area IIIproduction area, for processing, willbe used for the purpose stated above, and will
not be placed in fresh market channels.
I/We agree to report on shipments received as the Committee may require and the Commissioner
and Secretary approve.
The undersigned certifies to the Committee, the Commissioner, and the Secretary that
potatoes received willbe used in accordance with current Marketing Order Regulations
for use onlyfor the purpose stated. I realize that the making of a false statement,
knowing itto be false, is a violationof Title 18, Section 1001, of the United States Code,
among other statutes which provide for fine and imprisonment.
NAME OF COMPANY
ADDRESS

(Street or Box #)

(City)

(State)

Order 948

Slate 01 COlorado MO Docket A-4

( Zip Code)

AUTHORIZED SIGNATURE_
-If you list "other processing" also show the specific use, as "other processing" is defined.
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