COLORADO POTATO ADMINISTRATIVE COMMITTEE

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Colorado Potato Administrative Committee					Phone:  970-352-5231
Area III - Northern Colorado 							Fax:  970-304-0861
	P.O. Box 1774
Greeley, CO 80632

POTATO ADMINISTRATIVE COMMITTEE APPLICATION FORM FOR 
CONSIDERATION OF APPROVAL AS A CANNER, FREEZER, OR OTHER PROCESSOR 
OR PREPEELER OF POTATO PRODUCTS FOR SPECIAL PURPOSE SHIPMENT REPORTS

TO:	Colorado Potato Administrative Committee
Northern Colorado Office Area III
P. O. Box 1774
Greeley, CO 80632
FROM: __________________________________________________________________________________________
(Applicant's Name)
I/We, __________________________________________________________________________________________
(The Above Named Applicant)
hereby apply to the Colorado Potato Administrative Committee (Committee) for approval as a "RECEIVER" of potatoes under the Committee's Special Purpose Permit for the purpose of 

_________________________________________________________________________________________________
(Canning, Freezing, Other Processing, or Prepeeling---List One**)

I/We hereby certify to the Committee, the Colorado Department of Agriculture (CDA), and the U.S. Department of Agriculture (USDA) that potatoes received from the Area III production area, for processing, will be used for the purpose stated above, and will not be placed in fresh market channels.

I/We agree to report on shipments received as the Committee may require and the CDA and USDA approve.

The undersigned certifies to the Committee, the Commissioner, and the Secretary that potatoes received will be used in accordance with current Marketing Order Regulations for use only for the purpose stated.  False certification, knowing it to be false, is a violation of title 18, section 1001, of the United States Code, among other statures, which provide for a fine, imprisonment, or both.

NAME OF COMPANY ______________________________________________

ADDRESS _______________________________________________________

AUTHORIZED SIGNATURE__________________________________________
**If you list "other processing" also show the specific use, as "other processing" is defined.

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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, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD).  USDA is an equal opportunity provider and employer.