FV-266-12 920-Kiwifruit Application for Inspection Waiver Form

OMB No. 0581-0189

KIWIFRUIT ADMINISTRATIVE COMMITTEE

APPLICATION FOR INSPECTION

(Waiver Form)

SECTION I (To be completed by shipper)

To: (Federal-State Inspection Program)

Office

I hereby request inspection of of

(No. & type of containers) (Variety)

of on at

(Fruit) (Date) (Place)

between the hours of . If inspection is not available and a waiver is issued to cover the above-described fruit, I will certify that it will meet all requirements of the Kiwifruit Administrative Committee.

(Date) (Name)

(Address)

SECTION II (To be completed by the Federal-State Inspection Program)

This will acknowledge your request for inspection. Inspection cannot be performed at the time and place specified and you are hereby assigned waive number: W-

To cover the fruit for which you requested inspection. You are reminded that you must report all shipments of fruit controlled by the Kiwifruit Administrative Committee, including those that move under waiver to the Kiwifruit Administrative Committee, 1521 “I” Street, Sacramento, CA 95814.

(Date) (Name)

FEDERAL-STATE INSPECTION PROGRAM

Office

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-266-12 (Rev. 9/13. Destroy previous editions.)