Form CAC 100 CAC 100 Citrus Grown in FL. Application for Repacking Certificat

OMB No. 0581-0189

CITRUS ADMINISTRATIVE COMMITTEE
PO Box 941058
Maitland, FL 32794
Phone: (321)-214-5252 or (407) 765-5940
[email protected]

APPLICATION FOR A REPACKING CERTIFICATE OF PRIVILEGE
20___ - 20___ SEASON
As required by Marketing Order No. 905 regulating the handling of oranges, grapefruit,
tangerines, and tangelos grown in Florida
_______________________________________________________________________
Business Name on Citrus Fruit Dealer’s License
Address (incl. City, State, Zip Code) ________________________________________________________
___________________________________________________________________________________
Phone No.:
Fax No.:

(_____) __________________________
(_____) __________________________

Hereby certifies and agrees to the following:
1. I (we) have obtained a license as a Citrus Fruit Dealer and request a Certificate of Privilege as a
Special Purpose Shipper from the date of this application to ____________________________.
(Citrus Fruit Dealer’s License Number _______________)
2. I (we) will deal only with fruit that has been positive lot identified, inspected and certified, as
defined in section 905.53 of Marketing Order No. 905.
3. All citrus fruit handled by me (us) will be from registered packinghouses.
4. I (we) hereby submit a list of suppliers of inspected and certified Florida citrus fruit described in
item 2 above, and the approximate number of boxes of Florida citrus fruit that will be handled
during the season. (Please attach separate sheet(s) showing supplier’s business name, address,
and packinghouse registration number.)

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 OMB
0581-0189. The time required to complete this information collection is estimated to average 5 minutes per response, including the time for
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of information.

CAC Form 100 (Rev. 12/2018. Destroy previous editions.)

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OMB No. 0581-0189

5. Citrus shipped under a Repacking Certificate of Privilege will:
a. adhere to the applicable minimum grade and size requirements under Marketing Order
No. 905;
b. be inspected by the Federal-State Inspection Program prior to the time such fruit is
received;
c. be packed in approved Florida Department of Citrus containers; and
d. be reported to the Committee as required in section 905.163, Reports of Shipments under
Repacking Certificate of Privilege.
_______________________________________

_______________________

____________

Authorized Signature of Licensed Citrus Fruit Dealer

Title

Date

False certification or knowingly making any false statement to the Secretary of Agriculture is a violation of title 18, section 1001,
of the United States Code, and is punishable by fine, imprisonment, or both.

Application for a Repacking Certificate of Privilege
Date: ___________________, 20___

The above “Application for a Repacking Certificate of Privilege” is hereby

□

approved

□

disapproved

for the period ____________________, 20___ through _______________________, 20___.
For the 20___-20___ season, you will be Repacking Certificate of Privilege No. ___________.

By: __________________________________________________
Manager, Citrus Administrative Committee
FAILURE TO COMPLY WITH ANY OF THE CONDITIONS STATED IN THIS DOCUMENT IS
GROUNDS FOR IMMEDIATE TERMINATION OF THIS CERTIFICATE OF PRIVILEGE.

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 made 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.

CAC Form 100 (Rev. 12/2018. Destroy previous editions.)

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