FGIS-942 Application for Designation

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
FEDERAL GRAIN INSPECTION SERVICE
QUALITY ASSURANCE AND COMPLIANCE DIVISION
APPLICATION FOR DESIGNATION
TO PERFORM OFFICIAL FUNCTIONS UNDER THE U.S. GRAIN
STANDARDS ACT AS AMENDED

FORM APPROVED OMB NO. 0581-0309
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 uit nldeissp lays a valid
OMB control number. The valid OMB control number for this information collection is
0581-0309. The time required to complete this information collection is estimated to average 2
hours per response and 1 minute of recordkeeping, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information.
This application must be completed and approved before an individual or government
agency may be considered for designation to perform official functions under the U.S. Grain
Standards Act as amended (7 U.S.C. 79).

1. Name of Applicant (Exact name of private firm or state organization):

2. Area (identify the geographic area for which you are applying):

3. Scope of Services
Official Inspection

4a. Business location:

Official Weighing

4b. Business mailing address (if different from 4a):

5. Telephone number:

6. Fax number:

7. Email address:

A separate list may be furnished for the following information
8. Identify below the type of organization; and ownership, if a private agency.
State Organization – List names and titles of all officials (i.e., Commissioner, Director, Division or Bureau Chief, Official Agency Manager). An
organizational chart of the state bureau or department conducting inspection/weighing program should also be submitted.

Corporation – List names of stockholders and percent of ownership of each. List names of officers and directors.

Partnership – List name of partners and percentage of ownership of each partner.

Sole Proprietorship – List name of owner.

Other – Identify type and list ownership. List trustees, if any.

9. Furnish a list of names and mailing addresses (including zip code) of facilities requesting service.

10. Furnish the full address and location of each specified service point, whether it its full-time or applicant-specific, and inspection, weighing, or both.

11. Furnish a list of all non-licensed personnel, including the title of each person. A completed Conflict-of-Interest Questionnaire (Form FGIS – 100) must be
submitted for each non-licensed person listed.

12a. Name and title of Responsible Official:

12b.Name and title of manager or person responsible for the supervision and
management of the grain program. (if different from 12a.)

13. Signature of Responsible Official

14. Date

Form FGIS-942 (01/21) Previous editions are obsolete. Expires XX-XX

PRINT FORM

CLEAR FORM

Instructions for Completing FGIS-942
Please type application or print carefully. Additional sheets may be used for any item, if necessary.
1.

In box 1 provide the name of the individual, corporation, or state or local governmental agency applying for
designation.

2.

In box 2 describe the geographic area for which you are applying. If applying for part of an available area
for designation, include boundaries, such as state or county lines, and roads.

3.

In box 3 check official inspection, official weighing, or both.

4.

In box 4a provide the applicant’s address, using a street location.

5.

In box 4b provide the applicant’s mailing address, if different from 4a.

6.

In box 5 provide the applicant’s telephone number.

7.

In box 6 provide the applicant’s telefax.

8.

In box 7 provide the applicant’s electronic mail address.

9.

In box 8 check either “State Organization”, “Corporation”, “Partnership”, “Sole Proprietorship,” or “Other,”
and provide information requested in that box.

10.

In box 9 provide a list of names and mailing addresses of facilites requesting service (this may be customer
billing labels or other attachment.)

11.

In box 10 provide the full address and location of each specified service point. Indicate for each laboratory
if it is open full-time to all customers, or if it is an applicant specific laboratory for one customer. Indicate
what type of facility; whether inspection or weighing, or both. Describe the types of services to be offered to
customers at that location, i.e., inspection, official commercial, weighing.

12.

In box 11 list the persons (including their title) not licensed under the U. S. Grain Standards Act, and
complete a Form FGIS –100 “Conflict of Interest Questionnaire” for each non-licensed person.

13.

In box 12a type the name and title of the person signing the application.

14.

In box 12b type the name and title of the person responsible for the supervision and management of the
grain program, if different from 12a. Otherwise, leave blank.

15.

In box 13 the responsible official named in 12a must sign this block.

16.

In box 14 provide date signed.

Submission and Contact Information
Submit the Application for Designation (Form FGIS - 942) using any of the following methods:
•

E-mail: Send via electronic mail to [email protected]

•

Hand Delivery, Courier, or Mail send to:
Quality Assurance & Compliance Division, AMS, FGIS, USDA
1400 Independence Avenue, SW, Room 2409-S, STOP 3630
Washington, DC 20250.

For furthur information contact:
Director
Quality Assurance & Compliance Division
1400 Independence Avenue, SW, Room 2409
Washington, DC 20250
Email: [email protected]
AMS website: http://www.ams.usda.gov