Form PPQ-621 Application for General Permit to Engage in the Business

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 0579-0076. The time required to complete this information collection is estimated to average 1 hour 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.

OMB APPROVED 0579-0076 Exp. Date

U.S. DEPARTMENT OF AGRICULTURE ANIMAL AND PLANT HEALTH INSPECTION SERVICE PLANT PROTECTION AND QUARANTINE APPLICATION FOR PROTECTED PLANT PERMIT TO ENGAGE IN THE BUSINESS OF IMPORTING, EXPORTING OR RE-EXPORTING TERRESTRIAL PLANTS Regulated by 50 cfr 17.12 and 23.23

MAIL COMPLETED APPLICATION WITH CHECK TO: USDA-APHIS-PPQ-Permit Unit 4700 River Road, Unit 136 Riverdale, Maryland 20737-1236 (877) 770-6990

INSTRUCTIONS: One copy of this application must be accompanied by a check or money Order for $70.00 made payable to: Plant Protection and Quarantine. In addition, if you are importing wood products, "Regulated under 7 CFR 319.40", please complete PPQ Form 585. If you are importing regulated plant material, please complete PPO Form 587 in addition to this form.

1. NAME AND UNITED STATES ADDRESS OF APPLICANT

2. NAME OF BUSINESS

3. TELEPHONE NUMBER

4. FAX NUMBER

5. FORM OF BUSINESS ("X" one If applying as a business)

Corporation

Firm

Partnership

Other (specify)

5(a). DESCRIBE THE NATURE OF YOUR ACTIVITIES RELATING TO IMPORTING, EXPORTING, OR RE-EXPORTING PLANTS REGULATED BY 50 CFR 17.12 and 23.23

5(b). LIST THE NAME AND ADDRESS OF EACH PARTNER, OFFICER, DIRECTOR, HOLDER, AND OWNER OF 10% OR MORE OF VOTING STOCK, AND EMPLOYEE IN MANAGERIAL OR EXECUTIVE CAPACITY (use plain paper if additional space is needed)

6. ADDRESS(ES) WHERE PLANTS REGULATED BY 50 CFR 17.12 AND 23.23 WOULD BE GROWN OR STORED AND ANY OTHER LOCATION WHERE ACTIVITIES RELATED TO SUCH PLANTS WOULD BE CONDUCTED

7. STREET ADDRESS WHERE BOOKS OR RECORDS CONCERNING THE IMPORTATION, EXPORTATION OR RE-EXPORTING OF PLANTS REGULATED BY 50 CFR 17.12 AND 23.23 WILL BE KEPT

8. NAME AND ADDRESS OF THE PERSON AUTHORIZED TO MAKE RECORDS OR PLANT INVENTORIES AVAILABLE FOR EXAMINATION BY INSPECTORS

TELEPHONE NUMBER (Include Area Code):

I hereby certify that the information in this application Is complete and accurate to the best of my knowledge and belief. WARNING: Any alteration, forgery, or unauthorized use of this document is subject to civil penalties of up to $250,000 (7 U.S.C 7734(b)) or punishable by a fine of not more than $10,000, or imprisonment of not more than 5 years, or both (18 U.S.C 1001) for false statement:

9. SIGNATURE (partner or officer if a business) :

10. DATE

PPQ FORM 621 Previous edition is obsolete.

FEB 2012