FV-202 Application for Interstate/Intrastate Commerce Inspector

OMB APPROVED - NO. 0581-0125

REPRODUCE LOCALLY. Include form number and edition date on all reproductions.
U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

APPLICATION FOR
INTERSTATE/INTRASTATE
COMMERCE INSPECTOR'S
1/
LICENSE

According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a person is not required to a
collection of information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0581-0125. The time required to complete this information collection is estimated to average 30 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, gender
color , national
origin, gender, religion, age, disability, sexual orientation, marital or family status, political beliefs, parental status
or protected genetic information. (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 Center at 202-720-2600
(voice and TDD). To file a USDA's TARGET complaint of discrimination, write USDA, Director, Office of Civil Rights,
Room 326-W, Whitten Building, 14th and Independence Avenue, SW, Washington, DC 20250-9410 or call
202-720-5964 (Voice and TDD). USDA is an equal opportunity provider and employer.

NOTE: Applicants for this License must have at least 36 months of fresh fruit and vegetable grading experience as a USDA Licensee.
1. NAME (Last, First, Middle)

2. SOCIAL SECURITY NUMBER

3. BIRTHDATE (Month, Day, Year)

4. MAILING ADDRESS (City, State, ZIP)

5. CURRENT DUTY STATION (City, State, ZIP)

E-Mail:
6. IMMEDIATE SUPERVISOR'S NAME (Last, First, Middle)

7. TELEPHONE NUMBER

8. LIST ALL STATES IN WHICH YOU HAVE BEEN LICENSED AND SHOW THE TOTAL NUMBER OF MONTHS YOU WERE LICENSED BY THAT STATE:
STATE(S)

MONTHS

STATE(S)

MONTHS

STATE(S)

MONTHS

STATE(S)

MONTHS

STATE(S)

MONTHS

STATE(S)

MONTHS

9. LIST ALL PREVIOUS EMPLOYERS FOR THE PAST FIVE YEARS (if additional space is required, use back of this form):
EMPLOYER'S NAME

EMPLOYER'S ADDRESS (City, State, ZIP)

10. DID YOU GRADUATE FROM HIGH SCHOOL (if you have a GED, answer Yes)?

YES

DATE BEGAN

DATE ENDED

NO

11. IF NOT, WHAT IS THE HIGHEST GRADE THAT YOU COMPLETED?
12. HAVE YOU ATTENDED COLLEGE (if Yes, list below all colleges attended, use back if needed)?
NAME OF COLLEGE

YES

NO
TYPE OF DEGREE OR TOTAL
SEMESTER HOURS

COLLEGE ADDRESS (City and State)

13. LIST CHIEF UNDERGRADUATE SUBJECTS:
14. APPLICANT'S SIGNATURE

DATE

By signing above, I agree to abide by all Federal instructions governing the inspection of fruits and vegetables, whether given to me in writing
(handbooks, memorandums, etc.) or orally by the Federal Supervisor. I also agree to surrender my license card when so requested by the Federal
Supervising Inspector or upon termination of my employment with my current employer.
THE FOLLOWING TO BE COMPLETED BY APPROVING OFFICIALS ONLY
FEDERAL SUPERVISOR'S SIGNATURE

CHECK ONE:

DATE RECOMMENDED

Unrestricted License

Other (specify) _________________________________________________________________________________________________

Restricted License -- to what commodities? _________________________________________________________________________________________________
The State concurs in the need for an unrestricted license and agrees to send the applicant to a Federal Market Training class within two years from date of approval and
to provide other training as deemed necessary by the USDA Fresh Products Branch Chief.
STATE MANAGER'S SIGNATURE: _____________________________________________________________________________________________________________________

DATE: ________________________

REGIONAL DIRECTOR'S SIGNATURE: _______________________________________________________________________________________________________ DATE APPROVED: ________________________

Concurrence

Disapproval

BRANCH CHIEF'S SIGNATURE: ___________________________________________________________ DATE: _______________________

______________________________

FV-202 (07-03) Destroy previous editions.

1/ As defined in the Manual for Federal and Federal-State Shipping Point Supervisors, October 1992, and other Branch Directives, FPB-02 (01-94)