SC-237A Request for Audit Services (Business, farms)

United States Department of
Agriculture

OMB No. 0581-0125
Exp. Draft

AGRICULTURAL MARKETING SERVICE, SPECIALTY CROPS PROGRAM
REQUEST FOR AUDIT SERVICES

(This is the only acceptable form for fax or electronic submission to USDA for audit requests)
NOTE: Fill in all appropriate blocks. Requested services may be delayed because of incomplete information. Type of service requested must be selected below.
Services will be declined if the request is beyond our scope of certification. Once a request has been received, a USDA representative will make contact within 48
hours of receipt to schedule the audit.

DATE OF REQUEST:

ANTICIPATED DATE OF AUDIT:

AUDITEE INFORMATION

FARM / FACILITY INFORMATION

Company Name:
Street Address:
City, State & Zip:
Phone Number:
Fax Number:
E-mail:
Contact Person:

Location(s),
including noncontiguous sites
and fields:
(Please list here or
attach longer list)
Total Acres / Total
Sq. Feet to be
audited:

APPLICANT INFORMATION (responsible for payment)
Same as above (please still list Billing Account No.)
Company Name:
Phone Number:
Fax Number:
E-mail:
Contact Person:

Commodities to be
covered by the
audit (Please list
here or attach
longer list):

Billing Acct No.:

AUDIT PROGRAM REQUESTED (Please choose at least one)
Produce GAPs Harmonized Audit (choose scopes
below)
Field Operations & Harvesting
Post-harvest
Tomato Audit Protocol (choose scopes below)
Open-field Production and Harvesting
Packinghouse
Greenhouse
Packing and Distribution
Harmonized GAP Plus+ Audit (choose scopes below)
Field Operations & Harvesting
Post-harvest Operations
Tomato Audit Protocol (choose scopes below)
Open-field Production and Harvesting
Packinghouse
Greenhouse
Packing and Distribution
GroupGAP (also choose GAP audit service)

USDA Good Agricultural Practices and Good Handling
Practices (GAP&GHP) Audit (choose scopes below)
Part 1 – Farm Review
Part 2 – Field Harvest & Field Packing Activities
Part 3 – House Packing Facility
Part 4 – Storage & Transportation
Part 6 – Wholesale Distribution Center/Terminal Warehouse
Part 7 – Preventive Food Defense Procedures
Mushroom Specific GAP Audit (M-GAP)
Non-GAP Audit Services
Food Defense
GMP/Preventive Controls (currently the PSA)
Other: (please list any additional services, not already included
above)

ADDITIONAL
REMARKS

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 0581-0125. The time required to complete this information collection is estimated average 2 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.
Non-Discrimination Policy: 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 How to File a Program Discrimination Complaint 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.
SC-237A (Draft) (Previous editions are to be destroyed)