No Form number CO Potatoes (Area II) Special Purpose Shipment

OMB No. 0581-0178

San Luis Valley

Office – Area II

(719) 852-4684 FAX

[email protected]

Colorado Potato Administrative Committee

A

P.O. Box 348

1305 Park Avenue

Monte Vista CO 81144

(719) 852-3322

uthorization for

Special Purpose

Shipments

_____________________________________________________________________________________

This Authorization for Special Purpose Shipments is required for the shipment of potatoes for other than fresh market purposes. Special purpose shipments include charity, prepeeling, canning, freezing, and/or “other processing.” “Other processing” includes, but is not restricted to, dehydration, chips, shoestrings, starch and flour. It includes the application of heat or cold to such an extent that the natural form or stability of the potato undergoes a substantial change. Potatoes for special purposes are exempt from the requirements of grade, size, maturity, and inspection.

By signing this form, I certify to the Colorado Potato Administrative Committee - Area II (Committee), the United States Department of Agriculture, and the Colorado Commissioner of Agriculture that any special purpose shipments made pursuant to this Authorization will be made in accordance with marketing order regulations. I have read these regulations and I certify that I shall request a Certificate of Privilege from the Committee for each load of potatoes to be shipped for special purposes. I certify that all potatoes granted a Certificate of Privilege by virtue of this Authorization must be used for the purpose stated in each Certificate of Privilege. Any deviation or infringement of this privilege will be reported to the Committee promptly. I certify that I will not knowingly sell, or cause to be sold, potatoes which have been granted a Certificate of Privilege and are to be used in violation of said Certificate of Privilege. All or any part of the Certificate of Privilege not duly executed may be recalled or revoked at the discretion of the Committee and when violation of said Application and Certificate of Privilege are in evidence. It is agreed that the Committee will be notified of any shipments rejected by receivers of special purpose potatoes. False certification, knowing it to be false, is a violation of title 18, section 1001, of the United States Code, among other statures, which provide for a fine, imprisonment, or both.

Return this form by _____________ to the Committee office.

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Company Name

______________________________________ ______________________________________

Approved by Area II Business (or Street) Address

______________________________________ ______________________________________

Date City, State, and Zip Code

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Mailing Address (if other than above)

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Authorized Signature and Date

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To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD).  USDA is an equal opportunity provider and employer.

State of Colorado MO Docket A-4 (Rev. 10/2010. Destroy previous editions.)