SC-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 LICENSE1/

The following statements are made in accordance with the Privacy Act of 1974 (5 USC 552a). 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 to average 30 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the date needed, and completing and reviewing the collection of information

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)

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

09. DID YOU GRADUATE FROM HIGH SCHOOL (if you have a GED, answer yes)? YES NO 1 0. IF NOT, WHAT IS THE HIGHEST GRADE THAT YOU COMPLETED? 11. HAVE 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

12LIST CHIEF UNDERGRADUATE SUBJECTS:

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 (handbooks, memorandums, 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?

T he state concurs in the need for an unrestricted license and agrees to send the applicant to a Federal Market Training class within two years from date of approval and to provide other training as deemed necessary by the USDA Fresh Products Branch Chief. S TATE MANAGER’S SIGNATURE: DATE: R EGIONAL DIRECTOR’S SIGNATURE: DATE APPROVED: Concurrence Disapproval BRANCH CHIEF’S SIGNATURE: DATE:

SC-202 (rev. 06-2016) Destroy previous editions. 1/ As defined in the Manual for Federal and Federal-State Shipping Point Supervisors, October 1992, and other Branch Directives, FPB-02 (01-94)

OMB 0581-0125

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.

SC-202 (rev. 06-2016)