Form FV-237-A Request for Audit Services (Gov.)

UNITED STATES DEPARTMENT OF AGRICULTURE Agricultural Marketing Service REQUEST FOR AUDIT SERVICES Fruit and Vegetable Programs
(This is the only acceptable form for fax or electronic submission to USDA for audit requests) NOTE: Fill in all appropriate blocks. Requested services may be delayed because of incomplete information. Type of service requested must be selected below.
DATE OF REQUEST:				ANTICIPATED DATE OF AUDIT:
AUDITEE INFORMATION					FARM / FACILITY INFORMATION
Company Name:					Location:
Street Address:
City, State & Zip:					Total Acres / Total Sq. Feet to be audited:
Phone Number:
Contact Person:
APPLICANT INFORMATION					COMMODITIES TO BE COVERED BY AUDIT (Please List)
Company Name
Phone Number:
Fax Number:
E-mail:
Contact Person:
TYPE OF AUDIT SERVICES REQUESTED
Type of Audit(s) Requested (Please choose at least one)					Scope of GAP&GHP Audit (Please choose all that apply)
□ Good Agricultural Practices & Good Handling Practices (GAP&GHP) (Select Audit Scopes)					□ Part 1 – Farm Review
					□ Part 2 – Field Harvest & Field Packing Activities
□ Mushroom Specific GAP Audit (M-GAP)
					□ Part 3 – House Packing Facility
□ Tomato Audit Protocol (T-GAP)
					□ Part 4 – Storage & Transportation
□ Leafy Greens Audit (LGMA)
					□ Part 6 – Wholesale Distribution Center / Terminal Warehouse
□ Identity Preservation Audit (IP)
□ Other, Specify:					□ Part 7 – Preventative Food Defense Procedures
ADDITIONAL REMARKS
To download a copy of the USDA Good Agricultural Practices & Good Handling Practices audit checklist, please visit the USDA website at http://www.ams.usda.gov/gapghp.
Once a request has been received, a USDA representative will make contact within 48 hours of receipt to schedule the audit.
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 0581-0125. The time required to complete this information collection is estimated average 2 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-237A (10-10)

FORM APPROVED BY OMB No. 0581-0125