FV-36 (rev. 8-11) Special Purpose Shipment Receiver Certification

REPRODUCE LOCALLY. Include form number and date on all reproductions. OMB No. 0581-NEW

IDAHO-EASTERN OREGON ONION COMMITTEE

PO BOX 909, PARMA, ID 83660

PHONE: 208-772-5111 FAX: 208-722-6582

SPECIAL PURPOSE SHIPMENT RECEIVER CERTIFICATION

If you plan to purchase onions grown in the Idaho-Eastern Oregon production area that do not meet fresh market requirements as stated in 7 CFR § 958.328, and intend them for canning, dehydrating, extracting, freezing, pickling, and/or experimentation, you must complete and submit this Certificate to the Idaho-Eastern Oregon Onion Committee (Committee). No shipment of onions for canning, dehydrating, extracting, freezing, pickling, and/or experimentation may be received from the Idaho-Eastern Oregon production areas unless this form is completed and returned.

CERTIFICATION STATEMENT:

I, the undersigned, hereby certify to USDA and to the Committee that all onions received at the address below from the Idaho-Eastern Oregon production area will be used for (check all that apply):

Canning Dehydrating Extracting Freezing Pickling Experimentation

I, further certify that none of these onions will be diverted to any fresh market outlet(s) except as expressly authorized by the Committee. In addition, I agree to submit such documents and reports to the Committee that may be requested for its auditing purposes. Falsification of information on this government document may result in a fine or imprisonment, or both (18 U.S.C. 1001).

Signature		Name
Title		Date
Receiver				Phone
Address
City		State			Zip Code

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 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.

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.

FV-36 (Rev. 04/2011. Destroy previous editions.)