CDAC-3 CA Dates-Application to be Placed on List of Approved Da

OMB No. 0581-0178

Send original and one signed copy to:

CALIFORNIA DATE ADMINISTRATIVE COMMITTEE

P.O. Box 1736

Indio, CA 92202-1736

Tel: (760) 347-4510 Fax: (760) 347-6374

APPLICATION TO BE PLACED ON THE LIST OF APPROVED DATE PRODUCT MANUFACTURERS

Application is made herewith to be placed on the California Date Administrative Committee (Committee) list of approved date product manufacturers for the purpose of using, or if not a handler of dates, acquiring and using, restricted and other marketable dates in the manufacture of products in which the dates lose their whole or pitted form.

In consideration of approval of this application, the undersigned agrees that all dates obtained for manufacturing into products will be used for that purpose. None will be resold or disposed of as whole or pitted dates, and within 24 hours of each completion of disposition of a lot of dates, a report of such will be filed with the Committee on form CDAC-8. In addition, at the end of each crop year, but no later than October 31, an annual report of operations will be filed on form CDAC-4.

The undersigned states that dates will be used to manufacture the following products:

The quantity of dates to be used for the twelve months, from October through September, is estimated to be ___________ pounds of the _________________________________________________ variety(ies).

All manufacturing of dates will occur at (plant location): _______________________________________________

I hereby certify to the U.S. Department of Agriculture and to the Committee that the information contained in this report is complete and accurate, and that the above agreement as to usage and reporting is acceptable.

Firm/Applicant: ______________________________________ By: ______________________________

Address: ____________________________________________ Title: _____________________________

City: _______________________________ State: _______ Zip Code: ____________

Date: ______________________________

The making of false statement or representation on this form, knowing it to be false, is a violation of title 18 section 1000 of the United States Code, which provides for the penalty of a fine or imprisonment, or both. This report is required by law (7 USC 608(d), 7 CFR 987.51, 987.151). Failure to report can result in a fine for each violation and each day during which such violation continues shall be deemed a separate violation.

Approval is subject to future revocation for cause by the Committee.

CALIFORNIA DATE ADMINISTRATIVE COMMITTEE

By: __________________________________________________ Date: _______________________________

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 0581-0178. The time required to complete this information collection is estimated to average 30 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 of 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, political beliefs, genetic information, 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.

CDAC-3 (Rev. 10/2010) Destroy previous editions.