No Form number WA Potato--Application Form for Consideration-approval a

OMB #0581-0178

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STATE

State of Washington Potato Committee

OF WASHINGTON

reTATO

P.o. Box 1815

Moses Lake,Washington98837

COMMITTEE

Potato Committee Application Form for Consideration of Approval as a Canner,
Freezer, Seed, Charity, Other Processor or Prepeeler of Potato Products

TO:

State of Washington Potato Committee
P.O. Box 1815
Moses Lake, Washington 98837

FROM (Applicant's

Name):
hereby apply to

l!we (Company/Business),

the State of Washington Potato Committee for approval as a "receiver" of potatoes under the Potato Committee's Special Purpose
permit for the purpose of
(Canning, freezing, seed, charity, other processing or prepeeling list one)**

-

Business/Plant Location(s):
Supplier(s)

Expected
State:

of

Potatoes

from

Washington

l!we hereby certify to the Committee and to the Secretary that potatoes received from the Washington State production area
for processing will be used forthe purposestated above,and will not be placed in fresh market channels.
l!we agree to report on shipments received as the Committee may require and the Secretary approve.
Theundersignedcertifiesto the Committeeand the Secretaryof Agriculturethat thesepotatoesare being usedin accordancewith
currentMarketingOrderRegulationsfor use only for the purposestated.I realizethat the makingof a falsestatement,knowingit to
be false,is a violationof Title 18, Section1001,of the UnitedStatesCode,amongotherstatuteswhichprovidefro fineand
imprisonment.

Address:
Phone:
Fax:
Email:
Signature:
**NOTE:Ifyou list "other processing". also show the specific use, as other processing is defined. Other processing includes,
but is not restricted to, dehydration, chips, shoestrings, starch and flour. It includes the application of heat or cold to such an
extent that the natural form or stability of the commodity undergoes a substantial change. The act of prepeeling, cooling,
slicing, dicing or applying material to prevent oxidation does not constitute "other processing."
Permissionis hereby granted/denied the above company to be added to the approved list of Special Purpose Receivers.
Manager:

Date:

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