FV-202 Application for Interstate/Intrastate Commerce Inspector

REPRODUCE LOCALLY, Include form number and edition date on all reproductions OMB APPROVED – NO. 0581-0125

U.S. DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE APPLICATION FOR INTERSTATE/INTRASTATE COMMERCE INSPECTOR’S LICENSE 1PU /

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 0581-0125. The time required to complete this information collection is estimated average 30 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, 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.

NOTE: Applicants for this License must have at least 36 months of fresh fruit and vegetable grading experience as a USDA Licensee.

1. NAME (Last, First, Middle)

E-MAIL

2. BIRTHDATE (Month, Day, Year)

3. MAILING ADDRESS (City, State, Zip)

4. CURRENT DUTY STATION (City, State, Zip)

5. IMMEDIATE SUPERVISOR’S NAME (Last, First, Middle)

6. TELEPHONE NUMBER

7. LIST ALL STATES IN WHICH YOU HAVE BEEN LICENSED AND SHOW THE TOTAL NUMBER OF MONTHS YOU WERE LICENSED BY THAT STATE:

STATE(S)

MONTHS

STATE(S)

MONTHS

STATE(S)

MONTHS

STATE(S)

MONTHS

STATE(S)

MONTHS

STATE(S)

MONTHS

8. LIST ALL PREVIOUS EMPLOYERS FOR THE PAST FIVE YEARS (If additional space is required, use back of this form):

EMPLOYER’S NAME

EMPLOYER’S ADDRESS (City, State, Zip)

DATE BEGAN

DATE ENDED

DID YOU GRADUATE FROM HIGH SCHOOL (if you have a GED, answer yes)? YES NO IF NOT, WHAT IS THE HIGHEST GRADE THAT YOU COMPLETED? AVE YOU ATTENDED COLLEGE (if yes, list below all colleges attended, use back if needed)? YES NO

NAME OF COLLEGE

COLLEGE ADDRESS (City and State)

TYPE OF DEGREE OR TOTAL SEMESTER HOURS

12. LIST CHIEF UNDERGRADUATE SUBJECTS

13. APPLICANTS SIGNATURE

DATE

By signing above, I agree to abide by all Federal instructions governing the inspection of fruits and vegetables, whether given to me in writing (Inspection Instruction, Administration, Inspection or Management (AIM) documents, etc.) or orally by the Federal Program Manager/Supervisor. I also agree to surrender my license card when so requested by the Federal Supervising Inspector or upon termination of my employment with my current employer.

THE FOLLOWING TO BE COMPLETED BY APPROVING OFFICIALS ONLY

FEDERAL PROGRAM MANAGER / SUPERVISOR’S SIGNATURE

DATE RECOMMENDED

CHECK ONE Unrestricted License Other (Specify) Restricted License – to what commodities?

The state concurs in the need for an unrestricted license and agrees to send the applicant to a Market Inspector Training class within two years from date of approval and to provide other training as deemed necessary by the USDA Director of the Specialty Crops Inspection Division. STATE MANAGER’S SIGNATURE: DATE: Concurrence Disapproval BRANCH CHIEF’S SIGNATURE: DATE:

FV-202 (7/14) Destroy previous editions. 1/ As defined in the current SCI Division Manual for Federal and Federal State Supervisors