Form FV-380 Order Form for Equipment & Miscellaneous Items

OMB 0581-NEW

Agricultural Marketing Service, Fruit & Vegetable Program, Specialty Crops Inspection Division

Order Form for Equipment and Miscellaneous Items

Complete form, call 650-552-9073 for shipping cost, total all items and e-mail, fax or mail to: USDA, AMS, FVP, SCI Division, Equipment & Forms Depot, 831 Mitten Road, Room 200, Burlingame, CA 94010

Phone 650-552-9073 ● Fax 650-552-9147, [email protected]

Products not sold by USDA should be ordered directly from the manufacturer.

For Internal Use:

Industry

Federal

Federal-State ●

Check

Credit

FV-218 Reimbursement

Invoice

Bill to:

Ship to:

Name:

Name:

Company:

Company:

Address:

Address:

City, State, Zip:

City, State, Zip:

Phone: Fax:

Phone: Fax:

Item Description

Quantity

Price Per Item

Total Cost

Subtotal

Check here for overnight delivery (additional charges apply)

Shipping

Total

Payment Information (all international and first-time customers must pay with a credit card):

Check enclosed (Payable to “USDA-AMS”)

Visa

MasterCard

American Express

Discover

Card Number

Expiration Date

CVV Code

Mailing Address for Card

Name on Card

Signature

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-NEW. The time required to complete this information collection is estimated to average five 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.

FV-380 (10-2015).

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:

1. mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410;

2. fax: (202) 690-7442; or

3. email: [email protected].

USDA is an equal opportunity provider, employer, and lender.

FV-380 (10-2015) Destroy previous editions.