No Form number South Texas Onion Committee Certificate of Privilege

OMB No. 0581-0178

SOUTH TEXAS ONION COMMITTEE

901 Business Park Drive, Suite 500 Mission, TX 78572

Phone: (956) 584-9331 Fax: (956) 584-0300

APPLICATION FOR CERTIFICATE OF PRIVILEGE

FOR SPECIAL PURPOSE SHIPMENT REPORTS

Handler Certificate of Privilege No.: ___________________

Effective Date: _______________ Expiration Date: ____________________

Certificates of Privilege for Special Purpose Reports are required for the shipment of onions for other than fresh market purposes.

Purpose of Shipment: □ Canning or Freezing □ Relief or Charity □Other ______________________

PERSON IN CHARGE OF SPECIAL PURPOSE FORMS: _____________________________________________

WHERE SHIPMENTS WILL ORIGINATE: ________________________________________________________

PLEASE LIST BELOW THE NAMES AND ADDRESSES OF CONSIGNEES YOU PLAN TO SEND SPECIAL PURPOSE ONIONS TO:

Name: __________________________________________ Name: _____________________________________

Name: __________________________________________ Name: _____________________________________

Name: __________________________________________ Name: _____________________________________

I, the undersigned applicant, understand and agree, that all onions granted a Certificate of Privilege for Special Purpose Shipments (Certificate), 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 South Texas Onion Committee (Committee) promptly. Further, I will not knowingly sell or cause to be sold onions which have been granted a Certificate of Privilege and are to be used in violation of Certificate. I acknowledge that making of a false or fraudulent statement for the purpose of influencing the actions of a government agency shall, upon conviction, be subject to a fine or imprisonment, or both (18 U.S.C. 1001).

_______________________________________________ ____________________________________

Company Name Authorized Signature

_____________________________________________________________________________________________

Mailing Address (Street or Box No., City, State, and Zip Code)

_____________________________________________________________________________________________

Physical Address (if different than above mailing address)

________________________________________ ____________________________________

Telephone Number Fax Number

FOR OFFICE USE ONLY: COMMITTEE APPROVAL: ______________________ DATE: _______

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 5 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 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.

Rev. 01/2014. Destroy previous editions.