CN-383-D HVI Color and Trash Calibration Standard Order Form

REPRODUCE LOCALLY

FORM APPROVED – OMB NO. 0581-0008

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
COTTON AND TOBACCO PROGRAM
DATE:

ORDER #
DO NOT WRITE IN THIS SPACE

Standardization & Engineering Division
3275 Appling Rd.
Memphis, TN 38133
Telephone: (901) 384-3030
Fax: (901) 384-3032
E-mail: [email protected]

PAID BY CHECK NO.

AMOUNT

RECEIVED BY

DATE

HVI Color and Trash Calibration Standard Order Form
ITEM

U.S.

Calibration Color Tile Set - 5 Tiles

L1

(Xenon)
Calibration Color Tile Set - Single Tile

L3

W

B

Y

G

C

EXPORT

FOB Memphis

$XXX.XX

Surface Delivery

$XXX.XX

FOB Memphis

$XX.XX

Surface Delivery

$XX.XX

L4

Color Check Box
(6 assorted cottons)

FOB Memphis

$XX.XX

Surface Delivery

$XX.XX

L5

Universal HVI Cotton Color Standard
(12 assorted cottons)

FOB Memphis

$XX.XX

Surface Delivery

$XX.XX

L6

Reassignment of Calibration Color Tile Set

FOB Memphis

$XX.XX

Surface Delivery

$XX.XX

M1

Trash Tile (1)
(Xenon)

FOB Memphis

$XX.XX

Surface Delivery

$XX.XX

M2

Cotton Images Under Glass
(6 Trash Levels)

FOB Memphis

$XXX.XX

Surface Delivery

$XXX.XX

M3

Single Cotton Image Under Glass
(Check One)

FOB Memphis

$XX.XX

Surface Delivery

$XX.XX

FOB Memphis

$XX.XX

Surface Delivery

$XX.XX

FOB Memphis

$XX.XX

Surface Delivery

$XX.XX

M4
M5

1

2

3

4

5

6

Leaf Guide Book (Check Type)
American Upland

American Pima

Tile Storage Box (Check Type)
Color Tile Box

Cotton Under Glass Box .

QUANTITY

Request Quote for
Air Freight Pre-Paid

DOLLAR
AMOUNT
$

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Air Freight Pre-Paid
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Air Freight Pre-Paid
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Air Freight Pre-Paid
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Air Freight Pre-Paid

Totals

$

PAYMENT MUST BE SUBMITTED WITH ORDER. WE DO NOT ACCEPT LETTERS OF CREDIT.
CHECK MUST BE DRAWN ON A U.S. BANK PAYABLE TO : USDA, AMS, COTTON AND TOBACCO PROGRAM.

ACCT. NO.
EXPIRES
SIGNATURE
CHECK
VISA
MC
PRICES: Price of standards includes packaging, handling and delivery where stated. Fumigation (if needed) is a minimum of $XX.XX per order.
Phytosanitary Certificate (if needed) is $XX.XX.
SHIP TO (print or type)
CONTACT NAME

COMPANY NAME

STREET ADDRESS (necessary)

POSTAL BOX

STATE, COUNTRY, AND ZIP CODE

E-MAIL ADDRESS

PHONE

CITY
FAX

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
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completing and reviewing the collection of information.
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and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity
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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.

CN-383D (Exp. X/XXXX) Destroy previous editions.