No Form Number ID/E.OR - Application for Cert. of Privilege for Spec. P

OMB No. 0581-0178

IDAHO-EASTERN OREGON POTATO COMMITTEE
3670 South 25th Street East
Idaho Falls, Idaho 83404
Phone: (208) 529-8057/Fax: (866) 672-6425

Certificate No.: _______________
Effective Date: _______________
Expiration Date: ______________

APPLICATION FOR CERTIFICATE OF PRIVILEGE
FOR SPECIAL PURPOSE SHIPMENT REPORTS
Certificate of Privilege for Special Purpose Reports are required for the shipment of potatoes for other than fresh market
purposes.
CHECK THE INTENDED USE FOR WHICH YOUR POTATOES WILL BE SHIPPED: □ CHIPPING
□ CANNING
□ FLAKE
□SHOESTRING
□CHARITY
□OTHER ___________________
CWT To Be Shipped: ____________________________________

Shipment Date: ______________________

Shipment Destination: __________________________________________________________________________
It is understood and agreed to by me, the undersigned applicant, that all potatoes granted a Certificate of Privilege for
Special Purpose Shipments (Certificate), by virtue of this application and corresponding Special Purpose Shipment
Reports, must be used for the purpose stated in this application and any deviation or infringement of this privilege which
shall become known to me will be reported to the Potato Committee promptly. Further, 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 Certificate. I am
aware that when Special Purpose Shipment Reports are used, the RECEIVER must return a copy of the report to the
Potato Committee within 15 days.
In addition to the penalties provided in 608(c)(14) of the Agricultural Marketing Agreement Act of 1937, as amended, I
acknowledge that under title 18, section 1001, of the United States Code, any person who knowingly makes a false or
fraudulent statement for the purpose of influencing the actions of a government agency shall, upon conviction, be subject
to a fine or imprisonment, or both.
______________________________________________
Authorized Signature
______________________________________________
Company Name

____________________________________
Approved by Potato Committee

______________________________________________
Address

______________________________________
Date

______________________________________________
City, State, and Zip Code

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disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs,
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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. 202509410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

Rev. 8/2012. Destroy previous editions.