923-Sweet Cherries Special Purpose Shipment Report

OMB No. 0581-0189

SPSC#_________

WASHINGTON CHERRY MARKETING COMMITTEE

105 S. 18^th STREET, SUITE 205

YAKIMA, WA 98901-2149

TELEPHONE: (509) 453-4837

FAX: (509) 453-4880

SPECIAL PURPOSE SHIPMENT REPORT

To be completed by G SHIPPER or G RECEIVER (please check applicable box):

Name ______________________________________________ Telephone ___________________________

Address __________________________________________________________________________________

(Street, City, State, and Zip Code)

Received from:

Grower/Handler Name (indicate grower or handler)	Sweet Cherry Variety	Pounds

I certify to the Washington Cherry Marketing Committee, the USDA, and the Washington State Department of Agriculture that any shipments made pursuant to this Special Purpose Shipment Certificate will be made in accordance with the current regulations under Marketing Order No. 923, Chapter 16-414 WAC, Cherries, Chapter 16-461 WAC, Inspection Requirements for Fruit and Vegetables, and Chapter 16-463 WAC, Prohibiting the Sale and/or Movement of Infested Cherries. Further, I agree to forward assessments due on these cherries to the Committee office.

Signature _______________________________________ Date _____________________________

NOTE: 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 0581-0189. The time required to complete this information collection is estimated to average 5 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. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

Rev. 7/10. Destroy previous editions.)