No Form number CO. Potatoes (Area III) Spec. Purpose (consideration of

OMB No. 0581-0178

Colorado Potato Administrative Committee Phone: 970-352-5231

Area III - Northern Colorado Fax: 970-304-0861

P.O. Box 1774

Greeley, CO 80632

POTATO ADMINISTRATIVE COMMITTEE APPLICATION FORM FOR

CONSIDERATION OF APPROVAL AS A CANNER, FREEZER, OR OTHER PROCESSOR

OR PREPEELER OF POTATO PRODUCTS FOR SPECIAL PURPOSE SHIPMENT REPORTS

TO: Colorado Potato Administrative Committee

Northern Colorado Office Area III

P. O. Box 1774

Greeley, CO 80632

FROM: __________________________________________________________________________________________

(Applicant's Name)

I/We, __________________________________________________________________________________________

(The Above Named Applicant)

hereby apply to the Colorado Potato Administrative Committee (Committee) for approval as a "RECEIVER" of potatoes under the Committee's Special Purpose Permit for the purpose of

_________________________________________________________________________________________________

(Canning, Freezing, Other Processing, or Prepeeling---List One**)

I/We hereby certify to the Committee, the Colorado Department of Agriculture (CDA), and the U.S. Department of Agriculture (USDA) that potatoes received from the Area III production area, for processing, will be used for the purpose stated above, and will not be placed in fresh market channels.

I/We agree to report on shipments received as the Committee may require and the CDA and USDA approve.

The undersigned certifies to the Committee, the Commissioner, and the Secretary that potatoes received will be used in accordance with current Marketing Order Regulations for use only for the purpose stated. False certification, knowing it to be false, is a violation of title 18, section 1001, of the United States Code, among other statures, which provide for a fine, imprisonment, or both.

NAME OF COMPANY ______________________________________________

ADDRESS _______________________________________________________

AUTHORIZED SIGNATURE__________________________________________

**If you list "other processing" also show the specific use, as "other processing" is defined.

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State of Colorado MO Docket A-4 (Rev. 10/2010. Destroy previous editions.)