No Form number WA Potato--Application Form for Consideration-Approval a

OMB No. 0581-0178

S tate of Washington Potato Committee

P.O. Box 1815, Moses Lake, Washington 98837

Phone (509) 765-8845/FAX (509) 765-4853

POTATO COMMITTEE APPLICATION FORM FOR CONSIDERATION OF APPROVAL

AS A CANNER, FREEZER, SEED, CHARITY, OTHER PROCESSOR, OR PREPEELER OF POTATO PRODUCTS

TO: State of Washington Potato Committee

P.O. Box 1815

Moses Lake, Washington 98837

FROM (Applicant’s Name): _______________________________________________________________________

I/We (Company/Business), __________________________________________________hereby apply to the State of

Washington Potato Committee (Committee) for approval as a “receiver” of potatoes under the Potato Committee’s Special Purpose permit for the purpose of ________________________________________________________________________.

(Canning, freezing, seed, charity, other processing or prepeeling - list one)**

Business/Plant Location(s):______________________________________________________________________________

Expected Suppliers of Potatoes from Washington State: _______________________________________________________

____________________________________________________________________________________________________

I/We hereby certify to the Committee and to the Secretary of Agriculture (Secretary) that potatoes received from the Washington State production area for processing will be used for the purpose stated above, and will not be placed in fresh market channels.

I/We agree to report on shipments received as the Committee may require and the Secretary approve.

The undersigned certifies to the Committee and the Secretary of Agriculture that these potatoes are being used in accordance with current Marketing Order regulations for use only for the purpose stated. The making of a false statement, knowing it to be false, is a violation of title 18, section 1001, of the United States Code, among other statutes which provide for fine and imprisonment.

Address: ___________________________________________________________________________________________

Phone: __________________________________ Email: __________________________________________________

Fax: ____________________________________ Signature: _______________________________________________

** If you list “other processing,” also show the specific use, as other processing is defined. Other processing includes, but is not restricted to, dehydration, chips, shoestrings, starch and flour. It includes the application of heat or cold to such an extent that the natural form or stability of the commodity undergoes a substantial change. The act of prepeeling, cooling, slicing, dicing or applying material to prevent oxidation does not constitute “other processing.”

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Permission is hereby granted/denied the above company to be added to the approved list of Special Purpose Receivers.

Manager: __________________________________________________ Date: _____________________

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Rev. 01/2014. Destroy previous editions.