FV-209 915-Avocados Application for Registered Handler

REPRODUCE LOCALLY. Include form number and date on all reproductions. OMB No. 0581-0189

U.S. DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE FRUIT AND VEGETABLE PROGRAMS		HANDLER REGISTRATION				Avocado Administrative Committee P.O. Box 900188 Homestead, FL 33090-0188 Tel: (305) 247-0848
In accordance with the authority granted by the Secretary of Agriculture for the marketing of avocados grown in Florida, under Marketing Order No. 915, I hereby apply for registration as an avocado handler, consistent with 7 CFR § 915.120.
NAME
2a. HOME ADDRESS (City, County, State, and Zip Code)
2b. BUSINESS ADDRESS (City, County, State, and Zip Code)
2c. HOME TELEPHONE NUMBER (include area code)			2d. BUSINESS TELEPHONE NUMBER (include area code)
ADDRESS WHERE FRUIT WILL BE PACKED
NAME OF PERSON RESPONSIBLE FOR PACKING FRUIT
FORM OF BUSINESS ORGANIZATION □ Individual □ Partnership □ Corporation □ Cooperative IF INCORPORATED, IN WHAT STATE?
NATURE OF BUSINESS □ Handler □ Trucker □ Shipper □ Gift fruit shipper
NUMBER OF YEARS ENGAGED IN AVOCADO BUSINESS			ESTIMATED SEASONAL VOLUME OF AVOCADOS HANDLED
NAME OF BUSINESS
IF OTHER THAN INDIVIDUAL, GIVE NAMES AND ADDRESSES OF OFFICERS, PARTNERS, ETC.
Name	Title				Address
WILL YOU HANDLE ONLY FRUIT THAT YOU, YOURSELF, OWN AND GROW? □ YES □ NO
NAME AND ADDRESS OF THREE REFERENCES, ONE OF WHICH SHALL BE A BANK
Name				Address
THE FOLLOWING FACILITIES ARE NEEDED FOR PACKING AVOCADOS, PLEASE INDICATE COMPLIANCE
Permanent location:
Facilities under cover:
Proper lighting:
Approved scales available:
Mark “X” in appropriate block								YES	NO
DO YOU HAVE A CURRENT PERISHABLE AGRICULTURAL COMMODITIES ACT (PACA) LICENSE*?
DO YOU HAVE A CURRENT FLORIDA DEALER’S LICENSE*?
DO YOU HAVE A CURRENT FLORIDA AGRICULTURAL BOND*?
DO YOU HAVE A CURRENT DADE COUNTY OCCUPATIONAL LICENSE*?
HAVE YOU, OR OTHER PRINCIPALS IN YOUR BUSINESS, EVER BEEN CONVICTED OF A FELONY?
ARE YOU AWARE OF THE PROVISIONS OF FEDERAL MARKETING ORDER NO. 915 THAT GOVERNS THE MARKETING OF AVOCADOS GROWN IN FLORIDA?
HAVE YOU READ AND STUDIED THE REQUIREMENTS FOR U.S. GRADE STANDARDS OF AVOCADOS?
DO YOU AGREE TO NOTIFY THIS OFFICE IMMEDIATELY IF THE ANSWER TO ANY OF THE PRECEEDING QUESTIONS CHANGE OVER TIME?
DO YOU UNDERSTAND THE CONDITIONS UNDER WHICH YOUR CERTIFICATE OF REGISTRATION MAY BE SUSPENDED OR REVOKED, AS OUTLINED IN 915.120 IN FEDERAL MARKETING ORDER NO. 915?
CERTIFICATION OF STATEMENT: I (we) hereby agree to comply with all of the requirements of the Marketing Order regulating the handling of avocados grown in the Florida production area and with all the rules and regulations issued thereunder.
SIGNATURE OF APPLICANT							DATE
STATE OF FLORIDA, COUNTY OF _____________________________. Before me the undersigned authority, personally appeared ____________________________________, who, being duly sworn, stated that he (she) is _________________________________ of ______________________________________, and that the statements contained herin are correct to the best of his (her) knowledge and belif. _________________________________________________ NOTARY PUBLIC
NOTE: The making of any false statements or representations in any matter within the jurisdiction of any agency of the United States, knowing it to be false, is a violation of Title 18, Section 1001, United States Code, which provides for a penalty of a fine of $10,000, or imprisonment of no more than five years, or both.

* A copy must accompany application.

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 15 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.

FV-209 (Rev. 7/10. Destroy previous editions.) Page 4 of 4