AMS-26 USDA Hemp Plan Producer Licensing Application

REPRODUCE LOCALLY. USDA HEMP LICENSE APPLICATION FORM. OMB No. 0581-0318

U NITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

USDA DOMESTIC HEMP PRODUCTION PROGRAM

USDA HEMP LICENSE APPLICATION

Instructions:

The U.S. Department of Agriculture (USDA) will accept applications from August 1st to October 31st of each year. All applications, whether new or for renewal, must comply with the requirements as described in 7 CFR Part 990. Once USDA approves an application, USDA will issue a producer license. Licenses are valid until December 31st of the third year from the date issued and do not automatically renew. Licenses must be renewed every three years and must include an updated criminal history report.

As part of the application process, individual applicants and key participants of a business must also submit a completed Federal Bureau of Investigation’s (FBI) Identity History Summary (https://www.fbi.gov/services/cjis/identity-history-summary-checks). USDA will not accept criminal history reports completed more than 60 days before the submission of an application.

USDA will approve or deny license applications within 60 calendar days, and applicants will be notified of the result either by letter or email.

All information submitted must be accurate, legible, and complete. Complete and submit this application along with your completed FBI Identity History Summary to:

By Mail: USDA/AMS/Specialty Crops Program Hemp Branch 470 L’Enfant Plaza S.W. Post Office Box 23192 Washington, D.C. 20026

Or via Fax at: (202) 720-8938

□ New Application □ Renewal Application

1) Personal Information.

Applicant Name: (First, Middle, Last)
Mailing Address: (Street, City, State, Zip Code)
Email Address:	Telephone Number:

2) Business Entity. (Only complete this section if applicant represents a business entity)

Entity Name and EIN Number:
Principal Business Address: (Street, City, State, Zip Code)	Business Email Address:
	Telephone Number:
Name (First, Middle, Last) and Title of Key Participants: (Each Key Participant must include a completed FBI Identity History Summary. Key Participants are persons who have a direct or indirect financial interest in the entity producing hemp, such as an owner or partner in a partnership.  A key participant also includes persons at executive levels including chief executive officer, chief operating officer and chief financial officer.) 1) 2) 3) Please attach any additional names to this application.

3) Criminal History Report (Include for both new applications and renewal applications)

Include a completed FBI Identity History Summary for each applicant and/or key participant of the business entity. More information on this process is available of the FBI website: https://www.fbi.gov/services/cjis/identity-history-summary-checks. The FBI Identity History Summary must be current and have been completed within 60 days of submission of this application. If the FBI Identity History Summary reveals that the applicant or a key participant has a felony conviction related to a controlled substance under State or Federal law that occurred within 10 years of the application, the applicant will not be licensed under the USDA Domestic Hemp Production Program.

4) Who has legal authority and ownership of the land on which you intend to grow hemp?

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By signing below, all applicants agree to abide by all rules and regulations of the USDA Domestic Hemp Production Program, 7 CFR Part 990, and certify the accuracy of the information provided in this application is accurate and truthful.

_____________________________________________________________________________________

Print Name (First, Middle, Last) Title Date Signature

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Print Name (First, Middle, Last) Title Date Signature

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Print Name (First, Middle, Last) Title Date Signature

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Print Name (First, Middle, Last) Title Date Signature

The following statements are made in accordance with the Privacy Act of 1974 (U.S.C.522a) and the Paperwork Reduction Act of 1995. The authority for requesting this information to be supplied on this form is the 7 CFR Part 990 Domestic Hemp Program (Program). The purpose of collecting this information is for USDA to administer the Program and the information provided on this form will be used to monitor Program participants. Failure to provide the information requested on this form may result in ineligibility to participate in the 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 0581-0318. The time required to complete this information collection is estimated to average 10 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.

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