FGIS 945 Application for Registration

UNITED STATES DEPARTMENT OF AGRICULTURE GRAIN INSPECTION, PACKERS AND STOCKYARDS ADMINISTRATION COMPLIANCE DIVISION APPLICATION FOR REGISTRATION UNDER SECTION 17A OF THE UNITED STATES GRAIN STANDARDS ACT , AS AMENDED		OMB Approved: OMB No. 0580-0013
		No Certificate of Registration may be issued unless a completed application has been received (7 U.S.C. 87f-1)
		According to the Paperwork Reduction Act of 1995, no agency may 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 0580-0013. The time required to complete this information collection is estimated to average 2 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.
1. Name of Applicant to be registered (individual or firm).
2a. Address (Street and number, city, state and zip code).	2b. Include mailing address if different than 2a.
3a. If a corporation or association, designate the state or foreign country in which incorporated.	3b. Date Incorporated
4. Full names of directors and principal officers (include titles) for business specified in item 1 above.
Name (Last, First, Middle Initial) __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________	Title __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________
5. List names of all persons with 10% or more ownership (control relationship) in the business specified in item 1 above.
________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________
6. List names and locations where applicant listed in item 1 above is engaged in buying, handling, weighing, or transporting grain for sale in foreign commerce.
Name __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________	Address (Street & No., City and State) __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________
7. Does applicant own 10% or more interest in any other business (es) engaged in buying, handling, weighing, or transporting grain for sale in interstate commerce? YES (If YES, answer questions 8 through 11) NO (If No, skip questions 8 through 11, go to item 12)

Form FGIS-945 (07-04) Previous editions are obsolete.

Form FGIS-945 (07-04) Previous editions are obsolete.

8. List the name(s) and location(s) for any interstate commerce grain business in which applicant has a control relationship. Attach a separate page for each such business.
Name	Address (Street & No. City and State and Zip Code)
9. List names and locations where business listed in item 8 above is engaged in buying, handling, weighing, or transporting grain for sale in interstate commerce. (Do not repeat name and address listed in item 8)
Name __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________	Address (Street & No. City and State and Zip Code) ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________
10. List full legal names of directors and principal officers (include titles) for the business specified in item 8 above).
Names of directors and offices	Titles
__________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________	____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________
11. Names of all persons with 10% or more ownership interest in business specified in item 8 above.
__________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________ __________________________________________________________________________________________________________
12. Person to contact regarding this application
Name Telephone No. (Include area code)
13. Registration Fee Annual Fee (See Instructions) $_________ Submit prescribed fee with completed application Payment should be by check, draft, or money order payable to: Federal Grain Inspection Service, USDA	CERTIFICATION: I certify that the answers given on this application for registration are true and correct to the best of my knowledge and belief.
	Signature
	Title	Date
PRIVACY ACT STATEMENT: Statutory authority to collect the above information is contained in Section 17A of the United States Grain Standards Act, as amended, (7 U.S.C. 871-1) and is mandatory to obtain the services, benefits or processes that you are seeking. The information furnished will be used by the Agency for the enforcement of the United States Grain Standards Act and the regulations promulgated thereunder and to provide the Agency with specific business information on grain facilities which are subject to registration requirement of the Act. The information will be used to issue Certificates of Registration and to evaluate possible conflicts of interest. Failure to provide all or part of the requested information will result in denial of a Certificate of Registration by the U.S. Department of Agriculture. 18 U.S.C. 1001 provides for a fine of not more than $10,000 or imprisonment for not more than 5 years or both, for false or fraudulent statements made to an Agency of the United States. FAILURE TO REGISTER WHEN REQUIRED IS A VIOLATION OF THE UNITED STATES GRAIN STANDARDS ACT AND SUBJECTS THE VIOLATOR TO ADMINISTRATIVE, CIVIL AND CRIMINAL PENALTIES SPECIFICALLY PROVIDED FOR IN THE ACT. Expires January 2015

INSTRUCTIONS FOR COMPLETING APPLICATION FOR REGISTRATION

-GENERAL-

Persons Required to Register:

Any person, who buys, handles, weighs or transports grain for sale in foreign commerce in excess of 15,000 metric tons in the preceding or current calendar year must register unless otherwise exempted by Section 17A of the United States Grain Standards Act. Persons required to register include, but are not limited to:

1. Any grain elevator, warehouse, or other handling facility that loads or ships any bulk or sacked grain in a final carrier or container in which the grain is to be transported from the United States (applicants with more than one such facility need only register once) or,

2. Any person who acquires ownership of grain thereafter directly exports such grain or causes such grain to be directly exported from the United States without further handling of such grain by a grain elevator, warehouse, or other grain storage or handling facility.

-INSTRUCTIONS-

APPLICANT– PLEASE PRINT OR TYPE FORM

Item No.

1. Enter the name of the individual, partnership, corporation, association, or other business entity regularly engaged in foreign commerce grain business. Regularly engaged in foreign commerce grain business is defined as the business of buying, handling, weighing, or transporting grain for sale in foreign commerce in excess of 15,000 metric tons in the preceding or current calendar year. An applicant with more than one such facility need to register only once.

2. Enter business address of applicant (include mailing address if different).

3. Enter the State or Foreign country in which the business is (e.g. corporation, association, etc.) incorporated and the date.

4. Enter the name(s) of directors and principal officers (include titles) for business specified in item 1.

5. Enter names of individuals, partnerships, corporations, associations, or other business entities with 10 percent or more ownership interest in the business specified in item 1. Ownership interest owned by a spouse, minor children, and relatives living in the same household must be included in determining the 10 percent ownership interest.

6. Enter the names and location where applicant listed in item 1 is engaged in buying, handling, weighing, or transporting grain for sale in foreign commerce.

7. If applicant owns 10 percent or more interest in any other business (es) engaged in buying, handling, weighing, or transporting grain for sale in interstate commerce please check “yes” and complete questions 8 thru 11. If not, please check “no” and then proceed to item 12.

8. Provide the information for each business that buys, handles, weighs, or transports grain for sale in interstate commerce in which:

1. The applicant owns 10 percent or more ownership interest or

2. The applicant has a control relationship (10 percent or more ownership interest) in any other business in which that business has a 10 percent or more ownership in any other firm engaged in buying, handling, weighing, or transporting grain for sale in interstate commerce. For example, Company A ( the applicant) owns 10 percent of Company B and Company B owns 10 percent or more ownership interest in firms C, D, and E. The applicant must provide the information for firms C, D, and E. List the firm name and address. Use a separate page to identify each additional business.

9. Enter names and locations where business listed in item 8 is engaged in buying, handling, weighing, or transporting grain for sale an interstate commerce. (Do not repeat name and address listed in item 8).

10. Enter full legal names of directors and principal officers including titles for the business specified in item 8.

11. Enter names of individuals, partnerships, corporations, associations, or other business entities with 10 percent or more ownership interest (control relationship) in the business specified in block 8. Ownership interest owned by a spouse, minor children, and relatives living in the same household must be included in determining the 10 percent ownership interest.

12. Please provide name and telephone number of an individual who has knowledge of information provided on this application.

13. If the answer to item 7 is NO, the annual fee is $135.

14. If the answer to item 7 is YES, the annual fee is $270.

The United States Grain Standards Act (USGSA), 7 U.S.C. 87f-1, requires the registration of all persons engaged in the business of buying grain for sale in foreign commerce. In addition, those individuals who handle, weigh, or transport grain for sale in foreign commerce must register.

The USGSA regulations, 7CFR 800.30-39, define foreign commerce grain business as persons who regularly engage in buying for sale, handling, weighing, or transporting grain totaling 15,000 metric tons or more during the preceding or current calendar year.

Contact: Prospective registrants should contact the Regulatory Branch of GIPSA's Compliance Division with questions or for application forms. Interested parties must submit registration applications in writing along with the required fee to:

USDA, GIPSA, FGIS, CP, Regulatory Branch

1400 Independence Avenue, SW

STOP 3604, Room 1647-S

Washington, DC 20250-3604

Telephone: 202-720-0203

Fax: 202-690-2755

Or via e-mail to: [email protected]