Form FAS-923 Certification Required to Apply for Dairy Import License

FAS-923 (REV. 7-96) OMB APPROVAL NO. 0551-0001

U.S. DEPARTMENT OF AGRICULTURE ■ FOREIGN AGRICULTURAL SERVICE

CERTIFICATION REQUIRED TO APPLY FOR DAIRY IMPORT LICENSES

1. CONTROL NUMBER	2. MAILING ADDRESS
3. APPLICANT NAME

4. NAME AND TITLE OF REPRESENTATIVE

5. AGENT FOR SERVICE OF PROCESS

6. TELEPHONE NUMBER

7. FAX NUMBER

8. IRS NUMBER

9. CHECK THE BOX TO IDENTIFY WHETHER YOU ARE APPLYING FOR LICENSE AS AN:

IMPORTER

EXPORTER

MANUFACTURER

This certification must be postmarked no earlier than September 1, and no later than October 15, and accompany all information required under §6.24 of the Import Regulation (7 CFR §§6.20-6.37). Incomplete applications will not be accepted. See reverse side of this form if eligibility is based on more than 8 import entries or export shipments.

LIST OF FIRM’S OWNERS -- TO BE COMPLETED BY THOSE APPLYING FOR A LICENSE.

(List additional owners on a separate sheet of paper).

NAME OF OWNER	Percent of Ownership	NAME OF OWNER	Percent of Ownership
WARNING: False statements made knowingly and willfully on this application or other supporting documents submitted therewith are punishable by fine and/or imprisonment under the provisions of 18 U.S.C. 1001. OFFICIAL CERTIFICATION STATEMENT: I, the duly authorized representative of the applicant, hereby request the issuance of historical, non-historical, and/or designated importer licenses. I certify that the applicant meets the applicable eligibility requirements of §6.23 of the Import Regulation. I also certify that the applicant is maintaining on file at the applicant’s premises, for audit and inspection by the USDA, all applicable records related to sales, purchases, and transactions, including all applicable records for entries used to qualify for eligibility, for a minimum of 5 years, as described in §6.30 of the Import Regulation. Additionally, I certify that the applicant will not obtain or use any license for speculation, brokering, or offering for sale, and will not permit any other person to use the license for profit. Furthermore, I understand that the Import Regulation prevents applicants who are affiliated with each other [as defined in §6.23(c)(4)], or who are associated with each other [as defined in §6.23(c)(5)], from receiving a non-historical license for the same article from the same country for the quota year.

SIGNATURE OF REPRESENTATIVE

DATE

E-MAIL ADDRESS

Pursuant to 5 CFR 1320.21 pertaining to the Paperwork Reduction Act of 1995, the following information is furnished on the public reporting burden for the collection of information in Forms pertaining to licenses issued under the Dairy Import Regulation (7 CFR Part 6). The estimated average burden hours for completing the currently approved Forms: (1) FAS-923, FAS-923A, and 923B (Rev. 7-96) (one form) is 405 hours; and (2) FAS-924A and FAS-924B (one form) is 21 hours. The estimated average burden includes the time for reviewing instructions, gathering data needed, completing Forms, and record keeping. Send comments regarding the burden estimate and/or any other aspect of this information collection, including suggestions for reducing this burden to the Department of Agriculture, STOP 6630,1400 Independence Ave., SW, Washington D.C. 20250-7630, and to the Office of Information and Regulatory Affairs, Office of Management and Budget, Washington, D. C. 20503.

Continuation Sheet -- Certification Required to Apply for Dairy Import Licenses

USE ONLY IF YOU ARE BASING YOUR ELIGIBILITY ON MORE THAN EIGHT (8) SHIPMENTS

OF IMPORTS OR EXPORTS.

Section 6.24(c) of the Import Regulation requires that you provide the following information about your additional import entries or export shipments. Do not list information from the import or export records which you are submitting with this application.
Import Entry Number (No shipment number for exports required)	Date of Import Entry or Date of Export Shipment	Import Volume or Export Volume