OMB No. 0581-0178
FLORIDA TOMATO COMMITTEE
800 Trafalgar Court, Suite 300 Maitland, FL 32751
Phone (407) 660-1949 Fax (407) 660-1656
20___-20___ APPLICATION FOR REGISTRATION AS TOMATO HANDLER
I hereby apply for registration as a Tomato Handler for the 20___-20___ season.
Physical address of all location(s) of grading and packing facilities in the production area:
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Type of business (Individual, Firm, Partnership, Corporation, Co-operative, Association or other business unit): _________________________________________________________________________________
If other than individual, show below names and addresses of the officers, partners, or other individuals having a financial interest in the business with the applicant.
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Address, City, State, Zip code |
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How many years have you been in the tomato business in Florida? ___________
Business Name of Applicant: ______________________________________________________________
Street Address: _________________________________________________________________________
City, State, Zip Code: ____________________________________________________________________
Mailing Address: _______________________________________________________________________
City, State, Zip Code: ____________________________________________________________________
Telephone Number: ___________________________ Fax Number: ________________________
Email address: __________________________________________________________________________
By: __________________________________________________ ________________________________
Authorized Signature and Title Print Name
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 5 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.
CRITICAL INFORMATION REQUEST
Please provide the information below for each grower who you expect will be shipping through your packing facility for the 20___- 20___ season. This information is needed to ensure that your growers are kept up-to-date on Florida Tomato Committee (Committee) activities and on subjects affecting the Florida tomato industry as a whole, such as: Medfly alerts; government regulations; labor situations; market conditions; etc. Return this form with your application for registration as a tomato handler.
GROWER NAME
CONTACT NAME
ADDRESS
CITY, STATE, ZIP CODE
TEL. NO.
GROWER NAME
CONTACT NAME
ADDRESS
CITY, STATE, ZIP CODE
TEL. NO.
GROWER NAME
CONTACT NAME
ADDRESS
CITY, STATE, ZIP CODE
TEL. NO.
GROWER NAME
CONTACT NAME
ADDRESS
CITY, STATE, ZIP CODE
TEL. NO.
GROWER NAME
CONTACT NAME
ADDRESS
CITY, STATE, ZIP CODE
TEL. NO.
(Make additional copies to list additional growers if necessary.)
FTC-102-75 (Rev. 10/2010. Destroy previous editions.)
| File Type | application/msword |
| File Title | September 14, 1998 |
| Author | Sandi Valerio |
| Last Modified By | Nel, Sasha |
| File Modified | 2010-11-23 |
| File Created | 2007-06-04 |