FV-237A Request for Audit Services

FORM APPROVED BY OMB No. 0581-NEW

UNITED STATES DEPARTMENT OF AGRICULTURE
Agricultural Marketing Service
Fruit and Vegetable Programs
Fresh Products Branch

REQUEST FOR AUDIT SERVICES

(This is the only acceptable form for fax or electronic submission to USDA for audit requests)
NOTE: Fill in all appropriate blocks. Requested services may be delayed because of incomplete information. Type of service
requested must be selected below.
DATE OF REQUEST:

ANTICIPATED DATE OF AUDIT:

AUDITEE INFORMATION
Company Name:

FARM / FACILITY INFORMATION
Location:

Street Address:
City, State & Zip:

Total Acres /
Total Sq Feet
to be audited:

Phone Number:
Contact Person:
APPLICANT INFORMATION

COMMODITIES TO BE COVERED BY AUDIT (Please List)

Company Name
Phone Number:
Fax Number:
E-mail:
Contact Person:

TYPE OF AUDIT SERVICES REQUESTED
Type of Audit(s) Requested (Please choose at least one)

Scope of GAP&GHP Audit (Please choose all that apply)

□ Good Agricultural Practices & Good Handling Practices

□ Part 1 – Farm Review
□ Part 2 – Field Harvest & Field Packing Activities
□ Part 3 – House Packing Facility
□ Part 4 – Storage & Transportation
□ Part 6 – Wholesale Distribution Center /

(GAP&GHP) (Select Audit Scopes)

□ Mushroom Specific GAP Audit (M-GAP)
□ Tomato GAP Audit (T-GAP)
□ Leafy Greens Audit (LGMA)
□ Identity Preservation Audit (IP)
□ Other, Specify: __________________________________

Terminal Warehouse

□ Part 7 – Preventative Food Defense Procedures

ADDITIONAL
REMARKS
To download a copy of the USDA Good Agricultural Practices & Good Handling Practices audit checklist, please visit the USDA
website at http://www.ams.usda.gov/gapghp.
Once a request has been received, a USDA representative will make contact within 48 hours of receipt to schedule the audit.
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-XXXX. The time required to complete this information
collection is estimated average .02 hours 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.

FV-237A (04-09)