DA-228 Request for Applicant Number

Export Health Certificate Request Forms

DA-228 9-2015

Export Certificates

OMB: 0581-0283

Document [docx]
Download: docx | pdf

Reproduce Locally Include form number and edition date on all reproductions

FORM APPROVED –OMB NO 0581-0272



U.S. Department of Agriculture

Agricultural Marketing Service

Dairy Programs


Request for Applicant Number


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. This valid OMB control number for this collection is 0581-0272. 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 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: The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 522a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting this information to be supplied on this form is the Agricultural Marketing Agreement Act of 1937, Secs. 1-19, 48 Stat. 31, as amended, (7 U.S.C. 601-674). Furnishing the requested information is necessary for the administration of this program. Submission of the Tax Identification Number (TIN) is mandatory, and will be used to determine affiliation or entity identity.

1. COMPANY NAME

AS REGESTERED WITH THE IRS

     

2. FEDERAL TAX ID NUMBER

     

3. DOING BUSINESS AS

IF APPLICABLE

     

4. BILLING ADDRESS LINE 1

     

5. BILLING ADDRESS LINE 2

     

6. CITY      

7. STATE   

8. ZIP CODE      

9. CONTACT

     

10. PHONE NUMBER

     

EXT      

11. FAX NUMBER

     

12. E-MAIL ADDRESS

     

13. COMPANY MAILING ADDRESS

(IF DIFFERENT THAN BILLING)

14. P.O. BOX AND/OR STREET ADDRESS

     

15. CITY, STATE, ZIP

     

16. CONTACT FOR MAILING ADDRESS

(IF DIFFERENT THAN BILLING)

     

17.E-MAIL FOR CONTACT

(IF DIFFERENT THAN BILLING)

     






MAIL TO:

PLEASE SUBMIT THE COMPLETED FORM TO THE DAIRY GRADING PROGRAM

PHONE: 630-437-5073

FAX: 630-437-5060

EMAIL: [email protected]


USDA, AMS, DAIRY

2150 WESTERN COURT, SUITE 100

LISLE, IL 60532

DA-228 (12/13)

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorKen Vorgert
File Modified0000-00-00
File Created2021-01-24

© 2024 OMB.report | Privacy Policy