F/H Form D Hazelnuts--Application to be Listed as an Accepted User

OMB No. 0581-0178

HAZELNUT MARKETING BOARD

21595-A Dolores Way NE

Aurora, OR 97002-9738

Tel: (503) 678-6823

Fax: (503) 678-6825

APPLICATION TO BE LISTED AS AN ACCEPTED USER OF

INEDIBLE HAZELNUTS AND HAZELNUT WASTE

TO: Hazelnut Marketing Board

An application is made herewith to be listed by the Hazelnut Marketing Board (Board) as an accepted user of inedible hazelnuts and hazelnut waste, and for approval of the use of such material in the outlet(s) checked below:

□ crushing for hazelnut oil

□ mixing into feed

□ feeding directly to livestock or poultry

This will occur at (location): ______________________________________________________________________

Street City

In consideration of the approval of this application, the undersigned agrees that all hazelnut material acquired from hazelnut handlers or growers will be used only for the purposes indicated, that none will be disposed of for human consumption and that Board employees may enter the applicant’s premises at any reasonable time to observe the storage or disposition of the material and to examine and audit the applicant’s transaction records. The undersigned also agrees to obtain from each handler an executed F/H Form ______ on each lot of material received and, upon crushing, mixing or feeding the hazelnuts, to execute part (b) of the form and mail it to the Board.

The undersigned hereby certifies to the U.S. Department of Agriculture and to the Board that the information supplied herein is complete and correct and that the above agreement as to usage and reporting is accepted.

Date ________________, 20_____ __________________________________________________

User Firm

__________________________________________________

Address

__________________________________________________

By

_________________________________________________

Title

Application is hereby approved, subject to revocation for cause:

Date ________________, 20_____ HAZELNUT MARKETING BOARD

__________________________________________________

By

__________________________________________________

Title

The making of any false statement or representation on this form, knowing it to be false, is a violation of title 18, section 1001 of the United States Code, which provides for the penalty of a fine or imprisonment of not more than five years, or both.

No approval can be obtained allowing a user of inedible hazelnuts and waste to make acquisition from a handler until the application form is received (7 U.S.C. 608 (d), 7 C.F.R. 984.64, 7 C.F.R. 984.464).

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 20 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.

F/H Form D (Rev. 10/2010) Destroy previous editions.