CAC 401 905 Citrus Grown in FL Grower Tree Run Certificate Appli

OMB No. 0581-0189

CITRUS ADMINISTRATIVE COMMITTEE

P.O. Box 24508

Lakeland, FL 33802-4508

Phone: (863) 682-3103

Fax: (863) 683-9563

[email protected]

APPLICATION FOR A GROWER TREE RUN CERTIFICATE

20___ - 20___ SEASON

Name of Grower

Address (incl. City, State, Zip Code

Phone No. (____) ______________________ Fax No. (____) ____________________

E-mail Address

Hereby certifies and agrees to the following:

1. All citrus fruit handled by me will be from my grove(s), and is subject to Florida statute chapter 601.9911 and 7 CFR 301.75.

2. Legal description of my grove(s):

3. Variety of citrus produced on the above listed grove(s):

4. Approximate number of boxes produced on the above identified grove(s):

5. All citrus fruit handled by me will be reported to the Citrus Administrative Committee as required in 7 CFR 905.149, Reports of Shipments under Grower Tree Run Certificate.

6. Each container must be identified by name and address, and any other information required by 7 CFR 301.75.

________________________________________________________ _____________

Grower Signature Date

False certification or knowingly making any false statement to the Secretary of Agriculture is a violation of title 18, section 1001, of the United States Code, and is punishable by fine not exceeding $10,000, five years’ imprisonment, or both.

The above application for a Grower Certificate is hereby approved/disapproved (circle one) for the period through July 31, 20___. For the 20___ - 20___ season, you will be Grower Tree Run Certificate No. ________________.

__________________________________________________ __________________

Manager, Citrus Administrative Committee Date

FAILURE TO COMPLY WITH ANY OF THE CONDITIONS STATED IN THIS DOCUMENT IS GROUNDS FOR IMMEDIATE TERMINATION OF THIS CERTIFICATE OF PRIVILEGE.

NOTE: 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 0581-0189. The time required to complete this information collection is estimated to average 5 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.

CAC Form 401 (Rev. 7/10. Destroy previous editions.)