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Form Approved – OMB No. 0581‐0031
PACA LICENSE RENEWAL APPLICATION
License Number
Anniversary Date
(barcode)
You are currently licensed under the Perishable Agricultural Commodities Act as described below. This license expires on the
anniversary date listed above. In order to renew the license for another year, please follow the instructions on the back of
this notice and return this notice by the anniversary date.
Questions? Contact the National License Center at 1‐800‐495‐7222 or email [email protected].
NOTICE TO LICENSEE
Bus:
Although no renewal fees are due, the form
must be completed and returned by the
anniversary date shown above. Failure to
return the form by the anniversary date will
result in a $50 reinstatement fee.
Phone:
EIN:
Fax:
Email:
State of Incorporation or Formation:
Type of Business:
Nature of Business:
Website:
Date of Incorporation or Formation:
Ownership Type:
No. of
Branches:
PRINCIPALS – Owner, Partners, Officers, Directors, Members and/or Managers and stockholders
Name (Last‐First‐ Middle Initial)
Home Address
Title
% of Stock
Please ensure that the information shown above is complete and correct. To make changes or additions, follow the instructions shown on
the back of this invoice. Operations without a license can result in an injunction plus civil penalty of $1200 for each offense plus $350 for
each day the offense continues.
Notice to Customers Making Payment by Check: As part of a Department of Treasury initiative, if you pay your account by check, it will be converted into an
electronic funds transfer (EFT). This means the bank will copy your check and use the account information on it to electronically debit your account for the
amount of the check. The debit from your account will usually occur within 24 hours and will be shown on your regular bank account statement. You will
not receive your original check back. The bank will destroy your original check but will keep the copy of it. If the EFT cannot be processed for technical
reasons, you authorize us to process the copy in place of your original check. If the EFT cannot be completed because of insufficient funds, the bank may try
to make the transfer up to 2 times at which point your account will be subject to additional administrative charges.
FV‐231‐2 (08‐10)
OMB Approved 0581-0031
PACA License Renewal Notice for Grocery Wholesalers and Retailers
Is all the information shown on the front of this form current and complete?
Yes
No
INSTRUCTIONS: If any of the information shown on the front of this form is NOT current or correct, report the changes or additions on the front or in the appropriate
space below. Attach a list of all branches with store name and full address. If the license is NOT being renewed, explain your reasons under “REMARKS.” This form
must be signed, returned, and received by the anniversary date shown on the front of this form.
Return Completed License Renewal Application by fax or mail to:
USDA, PACA Branch, National License Center
8700 Centreville Road, Suite 202
Manassas, VA 20110-8411
Fax: (703) 330-4555
FRUITS AND VEGETABLES HANDLED
(Item 3 on front)
Circle One
Fresh
Frozen
Questions, Call (800) 495-7222 or email [email protected]
Visit our website at www.ams.usda.gov/paca
NATURE OF BUSINESS
(Item 4 on front) Circle the one that best represents the predominant style of your operations
Both
Wholesaler
Commission Merchant
Broker
Retailer
Processor
Trucker
Food Service
UNDER “LEGAL STRUCTURE OF BUSINESS” (Item 5 on front) Has changed to: Circle One
Sole Proprietor
Corporation
Limited Liability Company
Partnership
Limited Partnership
Grocery Wholesaler
DATE OF CHANGE
Limited Liability Partnership
Association
Trust
Estate
CHANGES IN OWNERSHIP, PARTNERS, OFFICERS, DIRECTORS, MEMBERS and/or MANAGERS OF LLCs AND STOCKHOLDERS Please update all information requested
Changes
Add
Delete
Date of
Change
Main Business Phone Number
Changes
Add
Delete
Date of
Change
LEGAL NAME
Last, First, Middle Initial
Fax Number
Trade Name (dba) or
Branch
Social Security
Number
E-Mail Address
FULL HOME ADDRESS
Street, City, State, Zip Code
Title (Including % of Stock
Director)
Federal Employer Identification Number
Branch Locations
City and State
Signature and Title of Owner, Partner, Member/Manager (LLC) or Officer
completing the PACA License Renewal
Signature
Title
REMARKS
FV-231-2 (08-10) Reverse
Date
Note: The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 552a) and the Paperwork Reduction Act of 1995 The
authority for requesting this information to be supplied on this form is the Perishable Agricultural Commodities Act, 1930, as amended, (7 U.S.C. 499a499t) (499c, 499d). Furnishing the requested information is necessary for the administration of the Perishable Agricultural Commodities Act program.
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 0581-0031. The time required
to complete this information collection is estimated to average 3 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, or political
beliefs. (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.
| File Type | application/pdf |
| Author | FV_Profile |
| File Modified | 2010-08-19 |
| File Created | 2010-08-19 |