FTPP-231-1 PACA License Renewal Application

Form Approved – OMB No. 0581‐0031

PACA LICENSE RENEWAL APPLICATION
License Number

Anniversary Date

(barcode)

You are currently licensed under the Perishable Agricultural Commodities Act as described below. This license expires on the
anniversary date listed above. In order to renew the license for another year, please follow the instructions on the back of
this invoice and return the invoice with annual renewal fees by the anniversary date.
Questions? Contact the National License Center at 1‐800‐495‐7222 or email [email protected].

Renewal License Fees
Annual License Fee: $
Branch Fees:
$
TOTAL FEES DUE
$
THIS IS A BILL.
FOR PAYMENT INSTRUCTIONS, REFER TO THE
BACK OF THIS INVOICE.

Bus

Fax

Phone
EIN
Type of Business

Email
State of Incorporation or Formation
Nature of Business

Website
Date of Incorporation or Formation
Ownership Type

No. of Branches

PRINCIPALS – Owner, Partners, Officers, Directors, Members and/or Managers and stockholders
Name (Last‐First‐ Middle Initial)

Home Address

Title

% of Stock

Please ensure that the information shown above is complete and correct. To make changes or additions, follow the instructions shown on
the back of this invoice. Operations without a license can result in an injunction plus civil penalty of $1200 for each offense plus $350 for
each day the offense continues.

Notice to Customers Making Payment by Check: As part of a Department of Treasury initiative, if you pay your account by check, it will be converted into an
electronic funds transfer (EFT). This means the bank will copy your check and use the account information on it to electronically debit your account for the
amount of the check. The debit from your account will usually occur within 24 hours and will be shown on your regular bank account statement. You will
not receive your original check back. The bank will destroy your original check but will keep the copy of it. If the EFT cannot be processed for technical
reasons, you authorize us to process the copy in place of your original check. If the EFT cannot be completed because of insufficient funds, the bank may try
to make the transfer up to 2 times at which point your account will be subject to additional administrative charges.

FTPP‐231‐1 (02‐18)

PACA License Renewal Notice

OMB Approved 0581-0031

PACA License Number
Business Telephone Number

INSTRUCTIONS: Is all the information shown on the front of this form current and complete?

Yes
No If “No”, report the changes or additions on the front or
in the appropriate space below. If the license is NOT being renewed, explain your reasons under “REMARKS.” This form must be signed, returned with annual renewal fees, and
received by the anniversary date shown on the front of this form. Make checks payable to “USDA - PACA.” Please include the license number being renewed on the check.

Credit Card

Return Completed License Renewal Application and appropriate fees by mail to:
USDA, PACA Division
P.O Box 790327
St Louis, MO 63179-0327

Type of Card:

If paying by credit card, submit renewal by fax to (202) 260-8575

Account Number:

Visa

Exp Date:

Visit our website at www.ams.usda.gov/paca

Card Holder’s Name:

Fresh

Frozen

Discover

American Express

Questions, Call (800) 495-7222 or email [email protected]

FRUITS AND VEGETABLES HANDLED
(Item 3 on front)
Check One

Mastercard

/

Amount:

NATURE OF BUSINESS
(Item 4 on front) Check the one that best represents the predominant nature of your operations

Both

Wholesaler

Commission Merchant

Broker

Retailer

Processor

Trucker

Food Service

DATE OF CHANGE

UNDER “LEGAL STRUCTURE OF BUSINESS” (Item 5 on front) Has changed to: Check One
Sole Proprietor

Corporation

Limited Liability Company

Partnership

Limited Partnership

Grocery Wholesaler

Limited Liability Partnership

Association

Trust

Estate

CHANGES IN OWNERSHIP, PARTNERS, OFFICERS, DIRECTORS, MEMBERS and/or MANAGERS OF LLCs AND STOCKHOLDERS Please update all information requested
EIN
Date of
Changes
LEGAL NAME
FULL HOME ADDRESS
Title (Including
% of
Add Delete Change
Last, First, Middle Initial
Street, City, State, Zip Code
Director)
Stock

Main Business Phone Number

Changes
Add Delete

Date of
Change

Fax Number

Trade Name (dba) or
Branch

E-Mail Address

Federal Employer Identification Number

Branch Locations
City and State

Signature and Title of Owner, Partner, Member/Manager (LLC) or Officer
completing the PACA License Renewal
Signature
Title

REMARKS

FTPP-231-1 (02-18) Reverse

Date

Note: The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 552a) and the Paperwork Reduction Act of 1995.
The authority for requesting this information to be supplied on this form is the Perishable Agricultural Commodities Act of 1930, as amended,
(7 U.S.C. 499a-499t) (499c, 499d). Furnishing the requested information is necessary for the administration of the Perishable Agricultural
Commodities Act program.
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 0581-0031. The time
required to complete this information collection is estimated to average 3 minutes per response, including the time for reviewing instructions, searching
exist ing data sources, gathering and maint aining the data needed, and complet ing and reviewing the collect ion of informat ion.
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.