No Form number WA Potatoes -- Shippers Application for Special Purpose

OMB #0581-0178
Administering

Federal Marketing

Order Number 946, United States Department

of Agriculture

State of Washington Potato Committee
p.o. Box 1815, Moses Lake, Washington 98837

Telephone (509) 765-8845

Fax (509) 765-4853

SHIPPERS APPLICATION FOR SPECIAL PURPOSE CERTIFICATE
Special Purpose Certificate #:
Certificate Valid From: .
I request pennission to ship, grade and/or store and lor sell potatoes for Special Purpose. Under this
Special Purpose Certificate number, shipments of potatoes will be made for the following reason(s):
D Charity

D Prepeeling

D Experimentation

D Canning, fteezing, and/or "other processing"*
D Grading or storing in Morrow or Umatilla counties (OR)
* "Other processing" includes, but is not restricted to, dehydration, chips, shoestrings, starch and
flour. It includes the application of heat or cold to such an extent that the natural form or stability
of the commodity undergoes a substantial change. The act of prepeeling, cooling, slicing, dicing,
or applying material to prevent oxidation does not constitute "other processing."
To the best of your knowledge, please list the names of the companies receiving potato
shipments made under this Special Purpose Certificate, also please attach a separate sheet to
identify any additional receivers if needed.
Company Name:

Company Name:

Contact:

Contact:

Address:

Address:

City/State/Zip:

City/State/Zip:

Phone:

Phone:

Fax:

Fax:

Email:

Email:

Purpose:

Purpose:

Company Name:

Company Name:

Contact:

Contact:

Address:

Address:

City/State/Zip:
Phone:

City/State/Zip:

Fax:

Fax:

Email:

Email:

Purpose:

Purpose:

Phone:

SHIPPERS APPLICATION FOR SPECIAL PURPOSE CERTIFICATE
In consideration of your granting this permission, I agree to the following stipulations:
1.
That all companies/farms are to complete the shipper's application for special purpose certificates
even if a special purpose shipment is not made. If an unexpected shipment is made during the year to a
receiver that is not on the original application, I will inform the Committee in writing to add that receiver
to my application. That as each shipment is made under this Special Purpose Certificate, I will prepare a
Shipment Report on forms furnished by the Committee and/or recognize that those forms may be
submitted by a handler/processor on my behalf If a Committee form is to be used then one copy will be
mailed to the Committee and two copies will be forwarded to the receiver with instructions that the
receiver sign one copy and mail it to the Committee Office and retain the second copy for his files. Failure
of the receiver to promptly sign and return the Shipment Report will result in cancellation of permission to
ship potatoes under Special Purpose Certificate to this receiver.
2.
I certifYto the State of Washington Potato Committee and the Secretary of Agriculture that any
shipments made pursuant to this Special Purpose Certificate will be made in accordance with the current
Marketing Order Regulations. I have read these regulations and I made this application with full
knowledge thereof
COMPANY/FARM NAME:
CONTACT:
ADDRESS:
CITY /STATE/ZIP:
PHONE:
FAX:
EMAIL:
SIGNA TURE:
*************************************************************************************

ACTION BY THE ADMINISTRATIVE COMMITTEE FOR MARKETING ORDER NO. 946
Permission is hereby granted/denied the above shipper to ship potatoes for Special Purpose, as defined in
the regulations in effect at the time of shipment.

Manager:

Date:

AccordingtothePaperwork
Reduction
Actof 1995,anagencymaynotconductorsponsor,anda personis notrequiredto respondto a collectionof information
unlessit
displaysa validOMBcontrolnumber.ThevalidOMBcontrolnumberforthisinformation
collectionis0581-0178.Thetimerequiredtocompletethisinformation
collectionis
estimatedto average5 minutesperresponse,
includingthetimeforreviewing
instructions,
searching
existingdatasources,gathering
andmaintaining
thedataneeded,and
completing
andreviewing
thecollection
of information.
TheU.S.Department
ofAgriculture
(USDA)prohibitsdiscrimination
in allitsprograms
andactivitiesonthebasisof race,color,nationalorigin,age,disability,andwhere
applicable,
sex,maritalstatus,familialstatus,parentalstatus,religion,sexualorientation,
geneticinformation,
politicalbeliefs,reprisal,orbecauseallorpartofanindividual's
incomeisderivedfromanypublicassistance
program(Notallprohibited
basesapplyto allprograms.)Personswithdisabilities
whorequirealternative
meansfor
communication
ofprograminformation
(Braille,largeprint,audiotape,
etc.)shouldcontactUSDA'sTARGET
Centerat (202)720-2600
(voiceandTOO).Tofilea complaint
of
discrimination,
writeto USDA,Director,OfficeofCivilRights,1400Independence
Avenue,SW., Washington,
D.C. 20250-9410,
orcall(800)795-3272
(voice)or(202)7206382(TOD).USDAis anequalopportunity
providerandemployer.