915-Avocados Report of Special Purpose Shipment

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U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
FRUIT AND VEGETABLE PROGRAMS
REPORT OF SPECIAL PURPOSE SHIPMENT
UNDER CERTIFICATE OF PRIVILEGE
Avocado Administrative Committee
P.O. Box 900188
Homestead, FL 33090-0188
Tel: (305) 247-0848
SHIPPED TO

ADDRESS (City, County, State, and Zip Code)

NAME OF CARRIER

TRUCK LICENSE NUMBER
PURPOSE:  □  Seed		□  Charity (fresh)		□  Processing
NUMBERS OF CONTAINERS SHIPPED

CONTAINER WEIGHT
NUMBER OF CONTAINERS RECEIVED
CONTAINER WEIGHT
DATE SHIPPED

LOADING POINT
DATE RECEIVED
UNLOADING POINT
CERTIFICATION STATEMENT: The undersigned certifies to the Committee and the Secretary of Agriculture that these avocados are being shipped in accordance with current Marketing Order Regulations for use only for the purpose stated.  I realize that the making of a false statement, knowing it to be false, is a violation of Title 19, Section 1001, of the United States Code, among other statues, which provides for fine and imprisonment. 
If used other than stated by Shipper, specify:


CERTIFICATION STATEMENT: The undersigned acknowledges receipt of and certifies to the Committee and the Secretary of Agriculture that the above avocados will be used for the purpose indicated.  I realize that the making of a false statement, knowing it to be false, is a violation of Title 19, Section 1001, of the United States Code, among other statues, which provides for fine and imprisonment.
NAME OF SHIPPER


REGISTERED HANDLER NUMBER (if applicable)


PACA LICENSE NUMBER (if applicable)

NAME OF RECEIVER

ADDRESS (City, County, State, and Zip Code)

ADDRESS (City, County, State, and Zip Code)


SIGNATURE OF SHIPPER

SIGNATURE OF RECIEVER
SHIPPER INSTRUCTIONS:  Fill out this report for each Special Purpose Shipment.  Sign all four (4) copies.  Mail the original (white) copy to the Committee.  Forward the yellow and pink copies to the receiver. Retain the gold copy for your files.  FAILURE TO COMPLY CONSTITUTES A VIOLATION OF MARKETING ORDER NO. 915.
RECEIVER INSTRUCTIONS:  Upon receipt of these forms, promptly complete the pink copy and mail to the Committee.  Retain the yellow copy for your files.  FAILURE TO COMPLY WILL RESULT IN CANCELLATION OF CERTIFICATES PERMITTING SHIPMENTS OF SPECIAL PURPOSE AVOCADOS TO YOUR FIRM.



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