FTC-103 Application for Certified Tomato Repacker (966 FL. Tomat

OMB No. 0581-0178

FLORIDA TOMATO COMMITTEE Date: ___________, 20__

800 Trafalgar Court, Suite 300  Maitland, FL 32751

Phone (407) 660-1949  Fax (407) 660-1656

www.floridatomatoes.org

20___ - 20___

APPLICATION FOR CERTIFIED TOMATO REPACKER CERTIFICATE

I hereby make application for registration as a Certified Tomato Repacker for the 20___ - 20___ season.

1. Physical address of all location(s) of grading and packing facilities in the regulated area:

2. Type of business (Individual, Firm, Partnership, Corporation, Co-operative, Association, or other business unit): _________________________________________________________________________________

3. If other than individual, show below names and addresses of the officers, partners, or other individuals having a financial interest in the business with the applicant.

Name	Title	Address, City, State, Zip code

4. How many years has applicant been engaged in the tomato repacking business in Florida? _____________

Business Name of Applicant: ______________________________________________________________

Mailing Address: _______________________________________________________________________

City, State, Zip Code: ____________________________________________________________________

Mailing Address: _______________________________________________________________________

City, State, Zip Code: ____________________________________________________________________

Telephone Number: _______________________ Fax Number: ________________________

Email address: __________________________________________________________________________

By: __________________________________________________ ____________________________________

Authorized Signature Title

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.

FTC-103 (Rev. 01/2014. Destroy previous editions.)