FV-212 915-Avocados Report of Special Purpose Shipment

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 PROGRAM		REPORT OF SPECIAL PURPOSE SHIPMENT UNDER CERTIFICATE OF PRIVILEGE				Avocado Administrative Committee P.O. Box 900188 Homestead, FL 33090-0188 Tel: (305) 247-0848
SHIPPED TO
ADDRESS (City, County, State, and Zip Code)
NAME OF CARRIER					TRUCK LICENSE NUMBER
PURPOSE: □ Seed □ Charity (fresh) □ Processing
NUMBERS OF CONTAINERS SHIPPED			CONTAINER WEIGHT	NUMBER OF CONTAINERS RECEIVED				CONTAINER WEIGHT
DATE SHIPPED	LOADING POINT			DATE RECEIVED			UNLOADING POINT
CERTIFICATION STATEMENT: The undersigned certifies to the Committee and the Secretary of Agriculture that these avocados are being shipped in accordance with current Marketing Order Regulations for use only for the purpose stated. I realize that the making of a false statement, knowing it to be false, is a violation of Title 19, Section 1001, of the United States Code, among other statues, which provides for fine and imprisonment.				If used other than stated by Shipper, specify:
				CERTIFICATION STATEMENT: The undersigned acknowledges receipt of and certifies to the Committee and the Secretary of Agriculture that the above avocados will be used for the purpose indicated. I realize that the making of a false statement, knowing it to be false, is a violation of Title 19, Section 1001, of the United States Code, among other statues, which provides for fine and imprisonment.
NAME OF SHIPPER
REGISTERED HANDLER NUMBER (if applicable)
PACA LICENSE NUMBER (if applicable)				NAME OF RECEIVER
ADDRESS (City, County, State, and Zip Code)				ADDRESS (City, County, State, and Zip Code)
SIGNATURE OF SHIPPER				SIGNATURE OF RECIEVER
SHIPPER INSTRUCTIONS: Fill out this report for each Special Purpose Shipment. Sign all four (4) copies. Mail the original (white) copy to the Committee. Forward the yellow and pink copies to the receiver. Retain the gold copy for your files. FAILURE TO COMPLY CONSTITUTES A VIOLATION OF MARKETING ORDER NO. 915.				RECEIVER INSTRUCTIONS: Upon receipt of these forms, promptly complete the pink copy and mail to the Committee. Retain the yellow copy for your files. FAILURE TO COMPLY WILL RESULT IN CANCELLATION OF CERTIFICATES PERMITTING SHIPMENTS OF SPECIAL PURPOSE AVOCADOS TO YOUR FIRM.

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 6 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-212 (Rev. 9/13. Destroy previous editions.)