Warehouse Regulations Under the United States Warehouse Act

Instructions For WA-53

APPLICATION FOR A LICENSE TO INSPECT, CLASSIFY, SAMPLE, AND/OR WEIGH AGRICULTURAL PRODUCTS UNDER THE U.S. WAREHOUSE ACT

Applicants for personal licensing under the United States Warehouse Act to inspect, weigh, classify as to condition, grade, and class, and/or sample agricultural products within the authority of an existing United States Warehouse Act license use this form.

Submit the original of the completed form in hard copy or facsimile to the Kansas City Commodity Office (KCCO), Warehouse License and Examination Division, STOP 9148, P.O. Box 419205, Kansas City, MO 64141-6205; or FAX 816-926-1774. Customers who have established electronic access credentials with KCCO may electronically transmit this form to KCCO. Features for transmitting the form electronically are available to those customers with access credentials only. If you would like to establish online access credentials with KCCO, follow the instructions provided at the USDA eForms web site.

Applicants must complete Items 1 through 14. The warehouse operator completes the certification in Item 15. FSA completes the certifications in items 16 and 17.

Items 16 and 17 are for FSA use only.

 Fld Name/ Item No.	Instruction
A Name of Applicant	Enter the name of applicant.
B USWA License No.	Enter USWA license number.
C Fee	Enter fee.

Items 1 through 14

Fld Name/ Item No.

Instruction

1 Type of Service License Requested

Check the box indicating the services the applicant intends to provide. With a License to: Applicant will be Certifying: Inspect and Weigh Condition and Weight Inspect, Classify, and Weigh Condition, Class, Grade, and/or Weight Weigh Weight Classify Condition, Class, and/or Grade Sample No Certification) Sample, Classify and Weigh Condition, Class, and/or Weight Sample and Weigh Weight According to 7 CFR 735.200

2 Type of Warehouse	Check the box indicating the type of warehouse(s) at which the applicant will be providing the service requested in Item 1.
3 Type of Certification	Check the box indicating the certification the applicant intends to give. See the table in Item 1.
4 Facsimile or E-Signature	Check the box indicating whether the applicant needs facsimile or E-signature authority.
5 Name and address of Warehouse in which the applicant will performs the service	Enter the name of the warehouse and the city and state location in which the service will be performed.
6 Location of Warehouse	Enter the complete mailing address of the warehouse in which the service will be performed. (So that we may mail the license to the applicant.)

Fld Name/ Item No.	Instruction
7 Name and Address of Present Employer	Enter the name and address (city, state) of the licensed warehouse operator for whom the applicant will be performing the activities requested for licensing.
8 Date Employed	Enter the date (MM-DD-YYYY) employed by this warehouse operator.
9 Present Duties or Title	Enter present duties or the applicant’s job title with the current employer.
10 State the applicant’s experience (etc.)	Enter a summary of the applicant’s past experience with inspecting, grading, sampling, classing and/or weighing of agricultural products covered by this application including the number of years at a specific employer’s warehouse.
11 Is the applicant presently licensed (or has the applicant ever been licensed)?	Check the box indicating whether the applicant has ever held a USWA license. Enter any license number, dates of license, and the name of the employer for whom the applicant may have held a USWA license for a similar service.
12 Please indicate any special training (etc.)	Enter training course work completed including grain grading schools, seminars and the like along with dates of attendance.
13 A - D Give names and addresses (etc.)	13 A. Enter the names of four persons who know the applicant’s recent qualifications for the service(s) under application. The applicant’s most recent previous employer should be on this list. All others should not be the applicant’s immediate family or warehouses the applicant will service. 13 B. Enter the address of four persons who know the applicant’s qualifications for the service(s) under application. 13 C. Enter the telephone number of four persons who know the applicant’s qualifications for the service(s) under application. 13 D. Enter the occupation of four persons who know the applicant’s qualifications for the service(s) under application.
14 A-C Applicant’s Certification	14 A. Enter the applicant’s signature as the applicant wishes the license to be issued. 14B. Enter the date of the signature. 14C. Enter the applicant’s LEGIBLY printed name as the Applicant wishes it to appear on the license.
15 A-D Warehouse Operator’s Certification	15 A. Warehouse operator enters name of warehouse operator: Enter the warehouse operator’s full legal name and type of organization: For a proprietor, enter, for example “Susan Doe” . For a corporation, enter, for example, “Does, Inc.”, a BLANK corporation, where BLANK is the name of the state of incorporation. For a general partnership, enter, for example “Letitia Doe, Frank Doe, Selma Doe, and James Doe, copartners, trading as Doe Farms” then “under the laws of BLANK” where BLANK is the state under whose laws the partnership is organized. For a limited partnership, enter, for example “Doe Farms Limited Partnership under the laws of BLANK, Selma Doe, General Partner” where BLANK is the state of organization and under whose laws the applicant operate. For a limited liability company, enter, for example “Doe Farms, L. L. C., a BLANK limited liability company” where BLANK is the name of the state under which organized). 15 B. Enter the authorized signature. 15 C. Enter the signer’s title. 15 D. Enter the date (MM-DD-YYYY) signed.



Items 16 and 17 are for FSA use only.

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