No Form number OR/CA Potatoes--Handlers Application for Establishment o

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 ESTABLISHMENT OF

APPROVED MANUFACTURERS CLASSIFICATION

In consideration of the granting of an authorization for our company to be designated as an approved manufacturer of processing potatoes (potatoes not meeting the requirements of regulations for fresh market table stock), the undersigned agrees:

1. That all potatoes for commercial processing received by our company will be processed at the plant located at _____________________________________________________.

2. That potatoes received for processing will not be diverted to the fresh market.

3. That our company will report to the Committee all shipments of processing potatoes received from the Oregon-California production area. Such shipments will be reported by immediately submitting to the Committee the Special Purpose Shipment from sent by the shipper and received with the potato shipment. Such shipments will be identified by name of receiver, address of receiver, date received, hundredweight received, and special purpose for which the potatoes will be utilized. The form is to be signed and dated.

4. That failure to report, or the filing of false or incomplete reports, will result in the removal of my company from the list of approved manufacturers.

The principal potato products produced at our processing plant are________________________.

Company Name		Authorized Representative’s Signature
Address		Title
City, State, Zip code
Telephone Number		Fax Number

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.

Rev. 10/2010. Destroy previous editions.