WA-53 Applicaton for a License to Inspect, Classify, Sample, a

Form Approved – OMB No. 0581-0305

This form is available electronically. See Page 2 for Privacy Act and Paperwork Reduction Act Statements.

WA-53 U.S. DEPARTMENT OF AGRICULTURE (07-31-18) Agricultural Marketing Service APPLICATION FOR A LICENSE TO INSPECT, CLASSIFY, SAMPLE, AND/OR WEIGH AGRICULTURAL PRODUCTS UNDER THE UNITED STATES WAREHOUSE ACT					A. Print Applicant Name Clearly and Distinctly for Issuance of License
					B. USWA Warehouse License Number (REQUIRED)
NOTE TO APPLICANT: This application must be filled out and signed by the applicant. This application must be accompanied by a check or money order for the required fee and made payable to: “AGRICULTURAL MARKETING SERVICE, USDA.”							C. Fee $
I am applying for a license, under the United States Warehouse Act, to perform the services indicated in Item 2.
1. TYPE OF WAREHOUSE: Grain Cotton Cottonseed Dry Beans Nut Other:				2. TYPE OF SERVICE LICENSE REQUESTED: Inspect Weigh Sample Classify (Condition, Grade, Class)
3. TYPE OF CERTIFICATION: Grade Class Condition Weight	4. Facsimile Signature YES NO		5. DATE EMPLOYED (MM-DD-YYYY)			6. PRESENT DUTIES OR TITLE
7. Name and Location (City, State, Zip Code) of Warehouse where Services will be Performed			8. Name and Location (City and State) of Current Employer
9. State your experience in the actual inspection, grading, sampling, classing, and/or weighing of the agricultural products covered by this application, specifying the number of years with dates and names of employers. (REQUIRED)
10. Are you presently, or have you ever held a license for a similar service? YES NO (If “YES”, please indicate warehouse license number(s), service license number(s), location(s) and for whom the services were performed.)
11. Indicate any special training you have had pertinent to this application (i.e., grain grading schools, seminars, USDA related schools, etc.).

WA-53 (07-31-18) Page 2 of 2

12. APPLICANT’S CERTIFICATION “Knowing that false statements made to the Government are subject to penalty, I certify that I have not been convicted of a felony, that I am at least 18 years of age and physically capable to perform the duties required by the service(s) for which this application is made; that I have the skills and equipment needed to perform these service(s) in accordance with applicable standards; and if this application is to include weighing, I will not knowingly weigh on scales that I believe to be incorrect; and that the statements made in this application are true to the best of my knowledge. Further, as a condition to granting this license, I agree to comply with the terms of the United States Warehouse Act and its regulations.”
A. Applicant’s Signature		B. Date (MM-DD-YYYY)
13. WAREHOUSE OPERATOR’S CERTIFICATION
I certify that “The applicant is acceptable to perform the service(s) for which applied for at the warehouse operated by the undersigned and specified on this form.”
A. Name of Warehouse Operator (Legal Entity Name)		B. Phone Number
C. Authorized Signature	D. Title	E. Date (MM-DD-YYYY)
No license will be issued until approved by the Warehouse and Commodity Management Division.

NOTE: The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a - as amended). The authority for requesting the

information identified on this form is 7 CFR Part 735, and the United States Warehouse Act (Pub. L. 106-472). The information will be used to apply for individual 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. The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for USDA/FSA-2, Farm Records File (Automated) and USDA/FSA-3, Consultants File. Providing the requested information is voluntary. However, failure to furnish the requested information will result in a determination of ineligibility to obtain new licensing or retain existing licensing under the United States Warehouse Act.

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

0581-0305. The time required to complete this information collection is estimated to average 15 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 provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO THE WAREHOUSE AND COMMODITY MANAGEMENT DIVISION, STOP 9148, P.O. BOX 419205, KANSAS CITY, MO 64141-6205.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. USDA is an equal opportunity provider, employer, and lender.

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 Warehouse and Commodity Management Division, STOP 9148, P.O. Box 419205, Kansas City, MO 64141-6205; or FAX 844-930-0174. Customers who have established electronic access credentials with WCMD may electronically transmit this form to WCMD. 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 WCMD, 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. AMS completes the certifications in items 16 and 17.



Items 16 and 17 are for AMS 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.