FV-231-2 PACA License Renewal Application

Form Approved – OMB No. 0581‐0031

PACA LICENSE RENEWAL APPLICATION

License Number

Anniversary Date

(barcode)

You are currently licensed under the Perishable Agricultural Commodities Act as described below. This license expires on the anniversary date listed above. In order to renew the license for another year, please follow the instructions on the back of this notice and return this notice by the anniversary date.

Questions? Contact the National License Center at 1‐800‐495‐7222 or email PACALicense@ams.usda.gov.

NOTICE TO LICENSEE

Bus:

Although no renewal fees are due, the form must be completed and returned by the anniversary date shown above. Failure to return the form by the anniversary date will result in a $50 reinstatement fee.

Phone: Fax: Email: Website:

EIN: State of Incorporation or Formation:

Date of Incorporation or Formation:

Type of Business: Nature of Business: Ownership Type:

No. of

Branches:

PRINCIPALS – Owner, Partners, Officers, Directors, Members and/or Managers and stockholders

Name (Last‐First‐ Middle Initial) Home Address ^Title

% of Stock

Please ensure that the information shown above is complete and correct. To make changes or additions, follow the instructions shown on the back of this invoice. Operations without a license can result in an injunction plus civil penalty of $1200 for each offense plus $350 for each day the offense continues. Notice to Customers Making Payment by Check: As part of a Department of Treasury initiative, if you pay your account by check, it will be converted into an electronic funds transfer (EFT). This means the bank will copy your check and use the account information on it to electronically debit your account for the amount of the check. The debit from your account will usually occur within 24 hours and will be shown on your regular bank account statement. You will not receive your original check back. The bank will destroy your original check but will keep the copy of it. If the EFT cannot be processed for technical reasons, you authorize us to process the copy in place of your original check. If the EFT cannot be completed because of insufficient funds, the bank may try to make the transfer up to 2 times at which point your account will be subject to additional administrative charges.

FV‐231‐2 (06‐13)

PACA License Renewal Notice for Grocery Wholesalers and Retailers

_{Is all the information shown on the front of this form current and complete? Yes No}

OMB Approved 0581-0031

INSTRUCTIONS: If any of the information shown on the front of this form is NOT current or correct, report the changes or additions on the front or in the appropriate space below. Attach a list of all branches with store name and full address. If the license is NOT being renewed, explain your reasons under “REMARKS.” This form must be signed, returned, and received by the anniversary date shown on the front of this form.

_{Return Completed License Renewal Application by fax or mail to:}

USDA, PACA Branch, National License Center

8700 Centreville Road, Suite 202

Manassas, VA 20110-8411

_{Fax: (703) 330-4555}

Questions, Call (800) 495-7222 or email P[email protected]

Visit our website at www.ams.usda.gov/paca

FRUITS AND VEGETABLES HANDLED (Item 3 on front) Circle One Fresh Frozen Both	NATURE OF BUSINESS (Item 4 on front) Circle the one that best represents the predominant style of your operations Wholesaler Commission Merchant Broker Retailer Processor Trucker Food Service Grocery Wholesaler
UNDER “LEGAL STRUCTURE OF BUSINESS” (Item 5 on front) Has changed to: Circle One Sole Proprietor Corporation Limited Liability Company Partnership Limited Partnership Limited Liability Partnership Association Trust Estate		DATE OF CHANGE

_{CHANGES IN OWNERSHIP, PARTNERS, OFFICERS, DIRECTORS, MEMBERS and/or MANAGERS OF LLCs AND STOCKHOLDERS Please update all information requested}

Changes Add Delete

Date of Change

LEGAL NAME Last, First, Middle Initial

Social Security Number

FULL HOME ADDRESS Street, City, State, Zip Code

Title (Including Director)

% of Stock

Main Business Phone Number

Fax Number

E-Mail Address

Federal Employer Identification Number

Changes Add Delete

Date of Change

Trade Name (dba) or Branch

Branch Locations City and State

Signature and Title of Owner, Partner, Member/Manager (LLC) or Officer completing the PACA License Renewal Signature Title Date

REMARKS

Note: The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 552a) and the Paperwork Reduction Act of 1995 The authority for requesting this information to be supplied on this form is the Perishable Agricultural Commodities Act, 1930, as amended, (7 U.S.C. 499a- 499t) (499c, 499d). Furnishing the requested information is necessary for the administration of the Perishable Agricultural Commodities Act program. 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 0581-0031. The time required to complete this information collection is estimated to average 3 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, or political beliefs. (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-231-2 (06-13) Reverse