FGIS-944 Application for License Under the USGSA and/or the AMA o

This is a fillable form; fill out, print, sign original, and mail to service area GIPSA Field Office.
U.S DEPARTMENT OF AGRICULTURE
FEDERAL GRAIN INSPECTION SERVICE

FORM APPROVED: OMB No. 0580-0013

APPLICATION FOR LICENSE UNDER THE
UNITED STATES GRAIN STANDARDS ACT (USGSA)
AND/OR
THE AGRICULTURE MARKETING ACT (AMA) OF
1946

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 0580-0013. The time required
to complete this information collection is estimated to average 8 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.

INSTRUCTIONS: This application must be completed in English, be typewritten or printed in ink and forwarded to the local FGIS office.
1.

APPLICANT'S NAME

2.

BIRTHDATE (mm/dd/yyyy)

3.

APPLICANT'S COMPLETE HOME MAILING ADDRESS (Including
Zip Code)

4.

NAME OF EMPLOYING AGENCY

5.

SERVICE POINT WHERE APPLICANT WILL BE
STATIONED

6.

SUPERVISING FIELD OFFICE

7.

TYPE OF LICENSE FOR WHICH YOU
ARE APPLYING

8.

HAVE YOU EVER BEEN LICENSED BY FGIS TO
PERFORM USGSA/AMA FUNCTIONS?

USGSA
9.

10.

AMA

Yes

No

LICENSE FOR WHICH YOU ARE APPLYING:

WAREHOUSEMAN SAMPLER

SAMPLER

CONTRACT SAMPLER - (AMA)

TECHNICIAN

WEIGHER

INSPECTOR

CONFLICT OF INTEREST QUESTIONAIRE

USGSA License
Do you, your spouse, your minor children, or any blood relative immediately residing in your household, serve as an officer director, committee member, or employee of any
business entity owning or operating any grain elevator or warehouse, or engage in the merchandising, storage, commercial transportation, or other commercial handling
No
of grain? Yes
Do you, your spouse, your minor children, or any blood relative immediately residing in your household, have stock or other financial interest, directly, or indirectly, in any grain
No
elevator or warehouse, or any other business entity involved in the merchandising, storage, commercial transportation, or other commercial handling of grain? Yes
Do you know of any other matters, family relationships, or other personal relationships, which might give rise to an apparent or possible conflict of interest involving your present
No
employment and any business entity described above? Yes
AMA License
Are you, your spouse, or relatives residing in your household employed by, or receiving a financial consideration from a company that merchandises, handles, stores, or processes
No
agricultural commodities that you would be licensed to sample or inspect? Yes
Do you, your spouse, or relatives residing in your household have a financial interest in a company that merchandises, handles, stores, or processes agricultural commodities that you
No
would be licensed to sample or inspect? Yes
Do you, your spouse, or relatives residing in your household have a financial interest in any of the raw materials or companies providing the raw materials from which the
No
commodities that you would be licensed to sample or inspect are manufactured? Yes

Certification: Knowing that false or fraudulent statements to an Agency of the United States Government are subject to penalty (a fine of not more than $10,000 or imprisonment for
not more than 5 years, or both), (18 U.S.C. 1001). I declare that the foregoing statements are true to the best of my knowledge and belief. Further, as a condition to the granting of
this license, I agree to comply and abide by the terms of the USGSA, regulations and the AMA, regulations, thereunder and instructions prescribed by FGIS. I further understand
that the license issued to me will terminate 3 years from the date of issuance, unless renewed and that upon resignation or dismissal, my license will be suspended for 1 year
or its termination date.
11.

SIGNATURE OF APPLICANT

12.

13.

NAME and/or SIGNATURE AGENCY MANAGER

14. TI

DATE (mm/dd/yyyy)

TLE

15. DA

TE (mm/dd/yyyy)

USDA USE ONLY

16.Action
APPROVED

17. NAME and/or SIGNATURE (FIELD OFFICE)

18. DATE (mm/dd/yyyy)

DISMISSED

The following declaration is made pursuant to Public Law 93-579 (Privacy Act of 1974), solicitation of personal information. FGIS program Systems of Records includes
History Records for Licensed Nonfederal Employees. Statutory authority to collect personal information is contained in 7 U.S.C. et seq. Pursuant to Executive Order 9397 of
November 22, 1943, disclosure of your social security number is necessary to provide requested information. The principal purpose for the collection of this data is the
enforcement of the United Grain Standards Act and the Agriculture Marketing Act of 1943. The routine use of this information is to evaluate acceptability of applicant and to
evaluate/resolve possible conflicts of interest. The information may be referred to states or other federal agencies for purposes relating to verification of employment or
required records or reports. Information also may be referred to the Department of Justice or to other investigative and law enforcement agencies for investigation, prosecution
and/or administrative action resulting from violation of law, rule, regulation, instruction, or order, or to a Congressional Office in response to a constituent's request for release
of his/her record.
FORM FGIS-944 (06-07) previous editions are obsolete. This form also replaces Form FGIS-943, which is obsolete. Expires January 2015

Clear Form

Instructions for Completing Application for License
Official Agencies
Complete sections 1 - 15 on the Application with the following information:
1.

Applicant's Name. The complete name of applicant for license.

2.

Birthdate. The date of birth of the applicant (Month, Day, Year).

3.

Address. The applicant’s complete home mailing address, including zip code.

4.

Official Agency. The name of the employing official agency.

5.

Service Point. The service point location where the applicant will be stationed.

6.

Supervising Field Office. The FGIS field office that will supervise the applicant.

7.

Type of License. Place an “X” in the applicable box to indicate the type of license the
applicant is applying for.

8.

Previous License. Place an “X” in the applicable box to indicate whether the applicant
has previously been licensed by FGIS.

9.

License applying for. Place an “X” in the applicable box to indicate the type of license
for which the applicant is applying.

10.

Conflict of Interest. The applicant must answer the appropriate USGSA/AMA questions
by placing a check in the appropriate boxes.

11.

Signature of Applicant. The applicant's signature.

12.

Date. The date the applicant signs the application.

13.

Name and/or Signature of Agency Manager. The printed name and/or signature of the
employing Official Agency Manager, or their designee.

14.

Title. The title of the approving official signing in block 13.

15.

Date. The date the application was signed by the Agency Manager or designee.

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Field Offices
Review the application, complete the section on the form reserved for FGIS use only.
Complete sections 16 – 18 on the Application with the following information:
16.

Action to be taken. Place an “X” in the appropriate box.

17.

Name and/or Signature of Field Office Manager. The printed name and/or signature of
the supervising Field Office Manager, or their designee.

18.

Date. The date the application was signed by the field office official.

Filing and Distribution Instructions
Official agencies
1.

Forward the original copy of the completed application to the supervising Field Office for
review. Retain a copy of the application (until the Field Office completes and returns the
application) for official agency records.

2.

After the Field Office reviews, completes, and returns the application, file a copy of the
completed application in the employee's licensing file.

Field Offices
1.

Retain the original copy of the completed form in the applicant's licensing file.

2.

Send a copy of the completed application to the Official Agency for their records.

If assistance is needed to complete this information please contact:
Field Management Division
Robert Lijewski
Telephone: (202) 720-0228
Fax: (202) 720-1015
Return form to the local FGIS office.
http://www.gipsa.usda.gov/GIPSA/webapp?area=home&subject=fc&topic=fsp

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