CDAC-11(a) (987) CA Dates--Clearance for Export of Dates to Mexico

OMB No. 0581-0178

Send one signed copy with 24 hours of disposition to:

CALIFORNIA DATE ADMINISTRATIVE COMMITTEE

P.O. Box 1736

Indio, CA 92202-1736

Tel: (760) 347-4510 Fax: (760) 347-6374

CLEARANCE FOR EXPORT OF DATES INTO MEXICO

___________________________________ located at _________________________________________________

Buyer’s Name Address, City, State, Zip Code, Country

Item No.	Variety	Classification: Export Mexico or Other	USDA Inspection Certification or Report Grading No.	No. of Containers	Type of Containers	Net Weight
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Carrier (truck driver) states that he/she will leave California and enter Mexico at ____________________ (point of entry) and his/her entry date will be approximately ______________________, 20___.

I hereby certify to the U.S. Department of Agriculture and to the California Date Administrative Committee (Committee) that the above-named buyer is party to an agreement that he will enter the fruit into Mexico, that he will not import the fruit to the United States or Canada, and that he holds a valid license from the Government of Mexico to import dates.

Selling Handler: __________________________________________________________

Signature of Authorized Agency: ____________________________________________

Title: ___________________________________ Date: _______________________

The making of a false statement or representation on this form, knowing it to be false, is a violation of title 18 section 1000 of the United States Code, which provides for the penalty of a fine or imprisonment, or both. This report is required by law (7 USC 608(d), 7 CFR 987.51, 987.151). Failure to report can result in a fine for each violation and each day during which such violation continues shall be deemed a separate violation.

Copies (three) must be distributed as follows:

Original and one copy: Truck driver to surrender original and one copy to U.S. Customs at Mexican border (al operador del camion ara entregar al U.S. Customs en la frontera Mexicana).

2^nd Copy: Send to the Committee for Selling Handler

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 0581-0178. The time required to complete this information collection is estimated to average 30 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.

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.

CDAC-11(a) (Rev. 01/2017) Destroy previous editions.