California Walnut Board OMB No. 0581-0178
101 Parkshore Drive, Ste. 250 CWB Export Form #B
Ph (916) 932-7070 Fax (916) 932-7071 Date: ______________________
In executing this form, the handler respectively certifies to the California Walnut Board and to the U.S. Department of Agriculture as to the correctness and completeness of their statement.
We have consummated sale of the reserve walnuts described below at the price recorded and hereby submitted with the required supporting documents:
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Net Weight (pounds) |
Size & Grade |
Inspection Certificate No. |
Price Per Pound |
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NAME OF CARRIER _____________________ SHIPPING CONTAINER NO. _______
(country)
Include the Following Information:
Copy of Invoice to Buyer No. ________________
Signed "On-Board" or
"Received for Shipment" No. ________________
Letter of Credit No. ____________________ Issued by:______________________________
(Name of Bank)
Date Paid __________________________
Cash in Advance:
Date payment received ____________________
Form of payment:
1) Check No. __________, issuing bank __________________, date _____________
2) Bank Draft No. ______________________, date ___________________________
3) Bank Transfer No. ____________________, date ____________________________
4) Other - specify _______________________________________________________
The making of any false statements or representations in any matter within the jurisdiction of any agency of the United States, knowing it to be false, is a violation of Title 18, Section 1001, United States Code, which provides for the penalty of a fine of $250,000 for individuals and $500,000 for organizations or imprisonment of not more than five years, or both.
Date Shipped _________________________________________________________________
Handler _____________________________________________________________________
By _________________________________________________________________________
Title _______________________________________________________________________
Note: No credit for reserve disposition for export by the handler in accordance with the export agent agreement can be obtained without first submitting this form to the California Walnut Board (7CFR 984.56(b), 7CFR 984.456(a)).
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 15 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.
Rev. 04/09
File Type | application/msword |
File Title | *WMB EXPORT FORM #B |
Author | Jodi Newman |
Last Modified By | usda |
File Modified | 2009-05-26 |
File Created | 2009-05-26 |