CDAC-3 (987) CA Dates-Application to be Placed on List of Appro

OMB No. 0581-0178

Send original and one signed copy to:

CALIFORNIA DATE ADMINISTRATIVE COMMITTEE

P.O. Box 1736

Indio, CA 92202-1736

Tel: (760) 347-4510 Fax: (760) 347-6374

APPLICATION TO BE PLACED ON THE LIST OF APPROVED DATE PRODUCT MANUFACTURERS

Application is made herewith to be placed on the California Date Administrative Committee (Committee) list of approved date product manufacturers for the purpose of using, or if not a handler of dates, acquiring and using, restricted and other marketable dates in the manufacture of products in which the dates lose their whole or pitted form.

In consideration of approval of this application, the undersigned agrees that all dates obtained for manufacturing into products will be used for that purpose. None will be resold or disposed of as whole or pitted dates, and within 24 hours of each completion of disposition of a lot of dates, a report of such will be filed with the Committee on form CDAC-8. In addition, at the end of each crop year, but no later than October 31, an annual report of operations will be filed on form CDAC-4.

The undersigned states that dates will be used to manufacture the following products:

The quantity of dates to be used for the twelve months, from October through September, is estimated to be ___________ pounds of the _________________________________________________ variety(ies).

All manufacturing of dates will occur at (plant location): _______________________________________________

I hereby certify to the U.S. Department of Agriculture and to the Committee that the information contained in this report is complete and accurate, and that the above agreement as to usage and reporting is acceptable.

Firm/Applicant: ______________________________________ By: ______________________________

Address: ____________________________________________ Title: _____________________________

City: _______________________________ State: _______ Zip Code: ____________

Date: ______________________________

The making of false statement or representation on this form, knowing it to be false, is a violation of title 18 section 1000 of the United States Code, which provides for the penalty of a fine or imprisonment, or both. This report is required by law (7 USC 608(d), 7 CFR 987.51, 987.151). Failure to report can result in a fine for each violation and each day during which such violation continues shall be deemed a separate violation.

Approval is subject to future revocation for cause by the Committee.

CALIFORNIA DATE ADMINISTRATIVE COMMITTEE

By: __________________________________________________ Date: _______________________________

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 0581-0178. The time required to complete this information collection is estimated to average 30 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.

CDAC-3 (Exp. x/xxxx) Destroy previous editions.