No Form number CO Potatoes (Area III) Certificate of Privilege, Special

OMB No. 0581-0178

Colorado Potato Administrative Committee Phone: 970-352-5231

Area III - Northern Colorado Fax: 970-304-0861

P.O. Box 1774

Greeley, CO 80632

APPLICATION FOR CERTIFICATE OF PRIVILEGE FOR SPECIAL PURPOSE SHIPMENT REPORTS

CERTIFICATES OF PRIVILEGE FOR SPECIAL PURPOSE REPORTS are required for the shipment of potatoes for other than fresh market purposes. CHECK THE INTENDED USE FOR WHICH YOUR POTATOES WILL BE SHIPPED.

_______CHIPPING _______CANNING _______FLAKE _______SHOESTRING ________CHARITY

_____OTHER (Please specify_______________________________________________________________________)

It is understood and agreed to by me, the undersigned applicant, that all potatoes granted a Certificate of Privilege for Special Purpose Shipments by virtue of this application and corresponding Special Purpose Shipment Reports must be used for the purpose stated in this application and any deviation or infringement of this privilege which shall become known to me will be reported to the Area III Colorado Potato Administrative Committee (Committee) promptly. Further, that I will not knowingly sell or cause to be sold potatoes which have been granted a Certificate of Privilege and are to be used in violation of said Certificate. I am aware that when Special Purpose Shipment Reports are used for OTHER THAN POTATOES FOR CHIPPING, the RECEIVER must return a copy of the report to the Committee within 15 days.

The Certificate of Privilege/Special Purpose Shipment Reports granted subject to this Application shall be numbered consecutively. All or any part of said Reports not duly executed may be recalled or revoked at the discretion of the Committee and when violation of said application and reports are in evidence. It is agreed that the Committee will be notified of any shipments rejected by receivers of processed potatoes.

False certification, knowing it to be false, is a violation of title 18, section 1001, of the United States Code, among other statures, which provide for a fine, imprisonment, or both.

Approved by Area III ___________________________________ Company Name: ________________________

Date: ________________________________________________ Business Address: ______________________

Forms Issued: City, State, Zip: _________________________

_______________ _______________ ______________ Mailing Address: _______________________

_______________ _______________ ______________ Authorized Signature: ___________________

_______________ _______________ ______________ Certificate of Privilege No. _______________

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 0581-0178. The time required to complete this information collection is estimated to average 9 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 USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

State of Colorado MO Docket A-4 (Rev. 01/2014. Destroy previous editions.)