Form FV-24 Positive Lot Identification Stamp/Die Request Form

FORM APPROVED BY OMB No. 0581-0125

UNITED STATES DEPARTMENT OF AGRICULTURE Agricultural Marketing Service Fruit and Vegetable Programs

POSITIVE LOT IDENTIFICATION STAMP(S)/DIE(S) REQUEST FORM

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 number. The valid OMB number for this information is 0581-0125. The time required to complete this information collection is estimated to average one hour per response, including the time for reviewing the instruction, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information

A. Stamp Description

Stamp Location (Applicant):

Stamp Manufacturer:

Stamp Manufacturer: Please reproduce, at the Applicant’s expense, _______ hand stamps or________ in-line coder printing dies bearing the approved USDA Federal-State Inspection logo with the following permanently affixed accountability number(s).

__ Inches

House Number

District Number

Inspection Number

Office/Market Number

___ Inches

B. Applicant’s Request

As a duly authorized agent of the above firm (Applicant), I hereby request that the above stamp/die order be approved and produced. I/We agree to be responsible for all charges assessed by the stamp manufacturer for this order. I also acknowledge that all stamps/dies ordered are the exclusive property of the United States Department of Agriculture and/or the___________________________________________________Federal-State Inspection Service. ______________________________________________________ ___________________________________ Applicant’s Authorization Signature Date of Request

E-Mail Address:

C. State/District Authorization

I have reviewed the above request and give approval for the order to be processed. _______________________________________________________ ___________________________________ State/District Authorization Signature Date of Request

D. Federal Authorization

All stamps/dies which make reference to or imply that a product has been USDA or Federal-State inspected are accountable items and are the property of the United States Department of Agriculture. No stamps/dies shall be produced without specific written consent of the Federal Program Manager/ Supervisor. _______________________________________________________ __________________________________ Federal Program Manager / Supervisor’s Signature Date of Authorization

NOTE:

These stamps/dies are to be mailed to the Federal-State District Supervisor who will distribute them.

MAIL STAMPS/DIES TO

E. Manufacturer’s Statement

I certify that each stamp/die produced by this firm bears a permanent accountability number and the only stamps/dies produced by this firm with markings referencing the USDA and/or the ______________________Federal-State Inspection Service are those that have been authorized in writing by the USDA. ________________________________________ ______________________________________ _________________________________ Manufacturer’s Signature of Compliance Title Date of Shipment

F. Local/District Receipt

I have received_______________ (quantity) stamp/dies bearing the following permanently affixed accountability number(s). ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ ____________ __________________________________________________________ ___________________________________________________________ District Supervisor’s Signature Date Received

G. Authorized PIQ-PLIDS Firm Representative/Inspector’s Receipt

I have received the above listed stamps/dies and they are now my responsibility. __________________________________________________________________ ___________________________________________________________________ Authorized Signature Date Received

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-24 (9/06) Previous editions may be used.