No Form number (946) WA Ptatoes--Shippers Application for Modification

OMB No. 0581-0178

S tate of Washington Potato Committee

P.O. Box 1815, Moses Lake, Washington 98837

Phone (509) 765-8845 / FAX (509) 765-4853

SHIPPER’S APPLICATION FOR MODIFICATION OF INSPECTION PRIVILEGE – POTATOES

Farm/Company Name: _______________________________________________ Contact Name: _______________________________

Address: ___________________________________________________________________________________________________________

Phone: ______________________________ County: ____________________________

Acres Variety Approximate yield per acre

_____ ______ ___________________

_____ ______ ___________________

_____ ______ ___________________
_____ ______ ___________________

_____ ______ ___________________

Type of Pack Made:

Consumer Packs: __________ Cartons:__________ 25# Sacks:__________ 50# Sacks:__________

(5’s, 10’s, 15’s, 20’s)

100# Sacks: ________ Tote Bins: __________ Bulk Loads: __________

Approximate packout per month (cwt):

_______ _______ _______ _______ _______ _______

January February March April May June

_______ _______ _______ _______ _______ _______

July August September October November December

Number of packers in area: _______________________

Location of nearest SWIS office: __________________

Approximate miles one way: ______________________

I, the undersigned applicant, agree to the following:

1. Comply with all the requirements of Marketing Order 946;

2. Promptly report all potatoes packed, shipped and marketed;

3. Promptly pay all inspection fees and assessments;

4. Apply annually for a renewal of permit;

5. Failure to comply with Marketing Order 946 may result in the cancellation of the Waiver permit.

6. Information provided is subject to verification by the SWPC and/or USDA.

____________________________________________________ ____________________

Signature of Applicant Date

Permission is hereby granted/denied to the above shipper for Modification of Inspection Privilege.

____________________________________________________ _____________________

Signature of Committee Chairman or Manager Date

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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.

(Exp. x/xxxx) Destroy previous editions.