No Form number OR-CA Potatoes Application for Certificate of Privilege

OMB No. 0581-0178

OREGON-CALIFORNIA POTATO COMMITTEE

9320 SW BARBUR BLVD., SUITE 130

PORTLAND, OREGON 97219-5405

Phone: (503) 731-3300 / Fax: (503) 239-4763

HANDLER APPLICATION FOR CERTIFICATE OF PRIVILEGE

Application is herby made for the issuance of a Certificate of Privilege for the 20___ - 20___ marketing year to permit me to divert potatoes, which do not meet regulations in effect at the time of such diversion, from fresh market channels to outlets specified in such regulations as Special Purpose Shipments.

In consideration of the Committee granting this Certificate, I agree to the following:

1. Potatoes for processing purposes will be shipped only to firms listed under the approved manufacturer of potato products classification established by the Committee.

2. I will report to the Committee all shipments to other outlets specified in the regulations as special purpose shipments.

I certify to the Oregon-California Potato Committee and the Secretary of Agriculture that any shipments made pursuant to this Certificate of Privilege will be made in accordance with the regulations of the Oregon-California Potato Committee.

Handler		Authorized Representative’s Signature
Address
City, State, and Zip Code
Telephone Number

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Rev. 10/2010. Destroy previous editions.