WA-302 Examination Report

This form is available electronically.

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

WA-302 U.S. DEPARTMENT OF AGRICULTURE (10-03-11) Farm Service Agency

1. Check One:

Original

EXAMINATION REPORT

Amendment

Subsequent

2. Code No.

3. License No.

4. Amendment No.

5. Date of License (MM-DD-YYYY)

6. Capacity

7. Type of Agreement

     

     

     

     

     

     

8. Name of Warehouse Operator (Legal Entity)      

12. Mailing Address of Headquarters Office (Including Zip Code) (Include Street Address for Express Delivery)

CHECK

     

 

9. Name of Warehouse

13. Location of Warehouse (City, County, Parish and State)

 

     

     

10. Mailing Address of Warehouse (Including Zip Code)

14A. Telephone Number (Area Code)

14B. Fax No.(Area Code)

 

     

     

     

11. Principal Place of Business      

14C. E-Mail Address (If Applicable)      

 

15A. Individual in Charge (Home Address (Including Zip Code))

 

     

Telephone Number (Area Code):

     

16. Type of Business Entity: Corporation Partnership Individual LLC

 

17. CORPORATION (Original Examination Only)

A. Charter Expires (Date) (MM-DD-YYYY)

B. Foreign Corporation Permit Issued By

Permit Expires (Date) (MM-DD-YYYY)

 

     

State of:      

     

D. Authorized Titles for Signatures

E. Authorized By:

 

By Laws Resolution

18. CORPORATE OFFICERS

A. President

B. Vice President

C. Vice President

 

     

     

     

D. Vice President

E. Treasurer

F. Secretary

 

     

     

     

19. PARTERSHIP (List names below if not shown above)

A. Type of Partnership (General, limited, etc.)      

 

B.

C.

D.

 

     

     

     

E.

F.

G.

 

     

     

     

20. LIMITED LIABILITY COMPANY

A. Operating Agreement

B. Articles of Organization

C. Authorized Titles for Signatures (If applicable)

D. Authorized By Operating Agreement

Articles of Organization

21. INDIVIDUAL

A. Name

B. Home Address (Including Zip Code)

 

     

     

Telephone Number (Area Code):

     

WA-302 (10-03-11) Page 2

22. Names of individuals authorized to sign warehouse receipt (Federally licensed houses only)

CHECK

A.

B.

C.

 

     

     

     

D.

E.

F.

 

     

     

     

23. Outstanding licenses issued to inspectors and weighers (Federally licensed houses only):

A. Name of Licensee

B. Service Performed

C. License Number

D. Where Posted

     

     

     

     

 

     

     

     

     

 

     

     

     

     

 

     

     

     

     

 

24. Is all storage space covered by this report included or to be included under license? If “NO”, explain on Form WA-101.

YES NO

25 Is warehouse open at least 6 hours each business day? If “NO”, explain on Form WA-101, the provisions made to receive, deliver, and settle on agricultural products?

YES NO

26. Name of Electronic Warehouse Receipt Provider (If applicable).

     

27. Does Warehouse Operator have any type of agreement with a field warehouse company? If “YES”, has this been cleared with USDA? If “NO”, furnish a copy to Examiner/KCCO.

YES NO

28A. Signature of Examiner

28B. Date (MM-DD-YYYY)

     

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 determine whether licensee has required facilities and is operating in accordance with the United States Warehouse Act, regulations, or contractual requirements. 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 30 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.