CN-383-G Commercial Standardization for Instrument Testing of Cot

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 Road
Memphis, TN 38133
Telephone: (901) 384-3030
Fax: (901) 384-3039
E-Mail: [email protected]

PAID BY CHECK NO.

AMOUNT

RECEIVED BY

DATE

Commercial Standardization for Instrument Testing of Cotton

CSITC Round Trial Participation Form
ITEM

DESCRIPTION

UNIT PRICE

Complete Program

12 Months

$xxx.xx

Quarterly

1st Quarter

$xx.xx

Quarterly

2nd Quarter

$xx.xx

Quarterly

3rd Quarter

$xx.xx

Quarterly

4th Quarter

$xx.xx

NUMBER OF SAMPLE
SETS

DOLLAR
AMOUNT
$

TOTALS

$

Number of Instruments to participate
(Maximum 2 instruments for each set of samples)
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.
CHECK

VISA

MC

ACCT NO.

EXPIRES

SIGNATURE

SHIP TO (print or type)
CONTACT NAME

COMPANY NAME

STREET ADDRESS (necessary)
POSTAL BOX

CITY

PHONE

STATE, COUNTRY AND ZIP CODE

E-MAIL ADDRESS

FAX

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

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
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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.
.

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