No Form number CO. Potatoes (Area II) Consideration of Approval as a Ca

OMB No. 0581-0178

San Luis Valley

Office – Area II

(719) 852-4684 FAX

[email protected]

Colorado Potato Administrative Committee

P.O. Box 348

1305 Park Avenue

Monte Vista CO 81144

(719) 852-3322

Application for Consideration of

Approval as a Canner, Freezer, or

Other Processor or Prepeeler of

Potato Products for Special Purpose Shipments

_________________________________________________________________________________________________

TO: Colorado Potato Administrative Committee

San Luis Valley Office Area II

P.O. Box 348

Monte Vista, CO 81144

FROM: _________________________________________________________________________________________

(Applicant's Name)

I/We __________________________________________________________________________________________

(The Above Named Applicant)

Hereby apply to the Colorado Potato Administrative Committee (Committee) for approval as a "RECEIVER" of potatoes under the Committee's Special Purpose Permit for the purpose of

_________________________________________________________________________________________________

(Canning, Freezing, Other Processing, or Prepeeling---List One**)

I/We hereby certify to Committee, the Commissioner of Agriculture for the State of Colorado (Commissioner), and the U.S Department of Agriculture (USDA) that potatoes received from the Area II production area, for processing, will be used for the purpose stated above, and will not be placed in fresh market channels.

I/We agree to report on shipments received as the Committee may require and the Commissioner and USDA approve. The undersigned certifies to the Committee, the Commissioner, and the Secretary that potatoes received will be used in accordance with current Marketing Order Regulations for use only for the purpose stated. 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.

NAME OF COMPANY ______________________________________________________________________________

ADDRESS _______________________________________________________________________________________

(Street or Box No.) (City) (State) (Zip Code)

AUTHORIZED SIGNATURE__________________________________________________________________________

**If you list "other processing" also show the specific use, as "other processing" is defined.

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