No Form Number ID/E.OR Potato Committee Application Form for Considerat

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
POTATO COMMITTEE APPLICATION FORM
FOR CONSIDERATION OF APPROVAL AS A CANNER, FREEZER, OR
OTHER PROCESSOR OR PREPEELER OF POTATO PRODUCTS
FOR SPECIAL PURPOSE SHIPMENT REPORTS
TO:

IDAHO-EASTERN OREGON POTATO COMMITTEE

FROM: __________________________________________________________________ (Applicant's Name)
I/We ________________________________________________________________________________________
The Above Named Applicant

hereby apply to the Idaho-Eastern Oregon Potato 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 the Committee and the Secretary of Agriculture (Secretary) that potatoes received from the IdahoEastern Oregon potato 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.
The undersigned certifies to the Committee and the Secretary that potatoes received will be used in accordance with
current Marketing Order regulations for use only for the purpose stated. The making of a false statement, knowing it to
be false, is a violation of title 18, section 1001, of the United States Code, which provides for a fine or imprisonment, or
both.
Name of Company _____________________________________________________________________________
Address _____________________________________________________________________________________
(Incl. City, State, Zip Code)

Authorized Signature ___________________________________________________________________________
**If you list “other processing,” also show the specific use, as “other processing” is defined.

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 9 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. 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.