SC-468 Application for License to Sample Processed Foods

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 LICENSE TO SAMPLE PROCESSED FOODS		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 10 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.
APPLICATION:  In accordance with the Regulations Governing Inspection and Certification of Processed Fruits and Vegetables and Related Products (7 CFR 52), I hereby apply for a license to sample processed products and to certify with respect to the identification, location, kind, and condition of the containers in the lots of such processed products drawn by me for applicants desiring inspection service under the cited regulations.
NAME AND ADDRESS (Include City, State, and ZIP) MR.       MS.        MRS.       E-mail Address:			SOCIAL SECURITY NUMBER
PRESENT AND PREVIOUS EMPLOYERS, PAST 10 YEARS:
INCLUSIVE DATES	NAME AND ADDRESS OF EMPLOYER		OCCUPATION OR DUTIES
FROM
TO PRESENT
FROM
TO PRESENT
FROM
TO PRESENT
FROM
TO PRESENT
PRIVACY ACT STATEMENT:  The following declaration is made pursuant to Public Law 93-579 (Privacy Act of 1974), Solicitation of Personal Information.  Statutory authority to collect personal information is contained in provisions of Executive Order 9397, dated November 22, 1943.  Submission of information is voluntary and there is no penalty for failure to provide requested information.  If, however, information is not provided, we will not be able to process your application.  Disclosure of your Social Security number is needed to obtain the services, benefits or processes that you are seeking.  The principle purpose for the collection of this data is personnel and payroll management of AMS programs.  The routine use of the information is referral to States and Federal Agencies for verification of employment and length of service for retirement purposes, and to the Department of Justice to process violations of law, whether civil, criminal, or regulatory in nature.
CERTIFICATION:   This is to certify that I agree, as a condition to the granting of the license applied for, to faithfully comply with all terms and conditions of the Regulations cited above with respect to the duties of a licensed sampler of the U.S. Department of Agriculture (USDA).  I will not as a licensed sampler, draw samples from any lot of processed products to which I or my employer is an interested party.  If my license is suspended or revoked, I will immediately surrender it to an appropriate USDA official.  The statements made by me in this application are true, complete, and correct to the best of my knowledge and belief.
SIGNATURE			DATE SIGNED

SC-468 (rev. 06-2016)       (Previous editions are to be destroyed)

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-468 (rev. 06-2016)