WA-53 Applicaton for a License to Inspect, Classify, Sample, a

This form is available electronically.

Form Approved – OMB No. 0560-0120 See Page 2 for Privacy Act and Paperwork Reduction Act Statements.

WA-53

U.S. DEPARTMENT OF AGRICULTURE

A. Name of Applicant

(10-03-11 )

Farm Service Agency

     

APPLICATION FOR A LICENSE TO INSPECT, CLASSIFY, SAMPLE, AND/OR WEIGH AGRICULTURAL PRODUCTS UNDER THE U.S. WAREHOUSE ACT

B. USWA License Number

     

NOTE TO APPLICANT: This application must be filled out and signed by the applicant. This application must be accompanied by a check or money order for the required fee and made payable to: “FARM SERVICE AGENCY, USDA.”

C.

Fee

$

     

I am applying for a license, under the United States Warehouse Act, to perform the services indicated in Item 1.

1.

TYPE OF SERVICE LICENSE REQUESTED: Inspect Weigh Classify (Condition, Grade, Class) Sample

3. TYPE OF CERTIFICATION: Grade Class Condition Weight

2. TYPE OF WAREHOUSE:

4. Facsimile Signature/E-Signature

Grain Cotton Cottonseed Dry Beans

YES NO

Nut Syrup Tobacco Other:

     

5.

Name and Address of Warehouse in Which You Will Perform the Service

6. Location of Warehouse (Complete Mailing Address including Zip Code)

     

     

7.

Present Employer’s Name and Address (Including Zip Code)

8.

Date Employed (MM-DD-YYYY)

9.

Present Duties or Title

     

     

     

10.

State your experience in the actual inspection, grading, sampling, classing, and/or weighing of the agricultural products covered by this application, specifying the number of years with dates and names of employers.

     

11.

Are you presently, or have you ever held a license for a similar service? and number, location, and for whom the services were performed.)

YES NO

(If “YES”, please indicate type of license and

     

12.

Please indicate any special training you have had pertinent to this application. Please include copies of certificates of training (i.e., grain grading schools, seminars, USDA related schools, etc.)

     

WA-53 (10-03-11) Page 2
13.	Give names and addresses of four persons, not of your immediate family, and not connected with any warehouse you will serve, who have personal knowledge of your qualifications. Include your most recent employer on this list, if any.
A. Name			B. Address (Street & No. or R.F.D. No. (Including Zip Code)		C. Telephone Number (Including Area Code)			D. Occupation
     			     		     			     
     			     		     			     
     			     		     			     
     			     		     			     
14. APPLICANT’S CERTIFICATION
“Knowing that false statements made to the Government are subject to penalty, I certify that I have not been convicted of a felony, that I am at least 18 years of age and physically capable to perform the duties required by the service(s) for which this application is made; that I have the skills and equipment needed to perform these service(s) in accordance with applicable standards; and if this application is to include weighing, I will not knowingly weigh on scales that I believe to be incorrect; and that the statements made in this application are true to the best of my knowledge. Further, as a condition to granting this license, I agree to comply with the terms of the United States Warehouse Act and its regulations.”
A. Applicant’s Signature						B. Date (MM-DD-YYYY)
						     
C. Print Name Clearly and Distinctly for Issuance of License
     
15. WAREHOUSE OPERATOR’S CERTIFICATION
I certify that “The applicant is acceptable to perform the service(s) for which applied for at the warehouse operated by the undersigned and specified on this form.”
A. Name of Warehouse Operator (Legal Entity)
     
B. Warehouse Operator’s Signature				C. Title			D. Date (MM-DD-YYYY)
				     			     
16. RECOMMENDATION OF U.S. WAREHOUSE EXAMINER IF APPLICABLE
A. I, attest that “I have determined that the applicant is qualified not qualified, and I recommend do not recommend issuance of the license applied for.”
B. Examiner’s Signature							C. Date (MM-DD-YYYY)
							     
17. DETERMINATION OF WAREHOUSE LICENSE AND EXAMINATION DIVISION (Kansas City Commodity Office)
A. I, attest that a telephone and/or written investigation of the applicant has been conducted by me and I recommend the following: Applicant Approved Applicant Not Approved
B. Reviewer’s Signature							C. Date (MM-DD-YYYY)
							     
NOTE: No license will be issued until approved by the Warehouse License and Examination Division (KCCO).
Note:		The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a - as amended).  The authority for requesting the information identified on this form is 7 CFR Part 735, 7 CFR Part 1423, 7 CFR Part 1427, the United States Warehouse Act (Pub. L. 106-472), and the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.). The information will be used to apply for individual licensing under the United States Warehouse Act to inspect, weigh, classify as to condition, grade, and class, and or sample agricultural products within the authority. The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for USDA/FSA-2, Farm Records File (Automated) and USDA/FSA-3, Consultants File.  Providing the requested information is voluntary.  However, failure to furnish the requested information will result in a determination of ineligibility to obtain new licensing or retain existing licensing under the United States Warehouse Act. 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 0560-0120. The time required to complete this information collection is estimated to average 15 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 provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO THE KANSAS CITY COMMODITY OFFICE, WAREHOUSE LICENSE AND EXAMINATION DIVISION, STOP 9148, P.O. BOX 419205, KANSAS CITY, MO 64141-6205.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all of 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, political beliefs, genetic information, 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, Assistant Secretary for Civil Rights, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, S.W., Stop 9410, Washington, DC  20250-9410, or call toll-free at (866) 632-9992 (English) or (800) 877-8339 (TDD) or (866) 377-8642 (English Federal-relay) or (800) 845-6136 (Spanish Federal-relay). USDA is an equal opportunity provider and employer.