SC-209 915-Avocados Application for Registered Handler

REPRODUCE LOCALLY. Include form number and date on all reproductions. OMB No. 0581-0189

U.S. DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE SPECIALTY CROPS PROGRAM		HANDLER REGISTRATION					Avocado Administrative Committee P.O. Box 900188 Homestead, FL 33090-0188 Tel: (305) 247-0848
In accordance with the authority granted by the Secretary of Agriculture for the marketing of avocados grown in South Florida, under Marketing Order No. 915, I hereby apply for registration as an avocado handler, consistent with 7 CFR § 915.120.
NAME			2a. EMAIL ADDRESS
2b. HOME ADDRESS (City, County, State, and Zip Code)
2c. BUSINESS ADDRESS (City, County, State, and Zip Code)
2d. HOME TEL. NUMBER (include area code)				2e. BUSINESS TEL. NUMBER (include area code)
ADDRESS WHERE FRUIT WILL BE PACKED
NAME OF PERSON RESPONSIBLE FOR PACKING FRUIT
FORM OF BUSINESS ORGANIZATION □ Individual □ Partnership □ Corporation □ Cooperative IF INCORPORATED, IN WHAT STATE?
NATURE OF BUSINESS □ Handler □ Trucker □ Shipper □ Gift fruit shipper
NUMBER OF YEARS ENGAGED IN AVOCADO BUSINESS				ESTIMATED SEASONAL VOLUME OF AVOCADOS HANDLED
NAME OF BUSINESS
IF OTHER THAN INDIVIDUAL, GIVE NAMES AND ADDRESSES OF OFFICERS, PARTNERS, ETC.
Name	Title					Address
WILL YOU HANDLE ONLY FRUIT THAT YOU, YOURSELF, OWN AND GROW? □ YES □ NO
NAME AND ADDRESS OF THREE REFERENCES, ONE OF WHICH SHALL BE A BANK
Name					Address

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 OMB 0581-0189. The time required to complete this information collection is estimated to average 15 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.

THE FOLLOWING FACILITIES ARE NEEDED FOR PACKING AVOCADOS, PLEASE INDICATE COMPLIANCE
Permanent location? Yes No	Facilities under cover? Yes No
Proper lighting? Yes No	Approved scales available? Yes No
Mark “X” in appropriate block			YES	NO
DO YOU HAVE A CURRENT PERISHABLE AGRICULTURAL COMMODITIES ACT (PACA) LICENSE? (A COPY MUST ACCOMPANY APPLICATION)
DO YOU HAVE A CURRENT FLORIDA DEALER’S LICENSE*?
DO YOU HAVE A CURRENT FLORIDA AGRICULTURAL BOND*?
DO YOU HAVE A CURRENT DADE COUNTY OCCUPATIONAL LICENSE*?
HAVE YOU, OR OTHER PRINCIPALS IN YOUR BUSINESS, EVER BEEN CONVICTED OF A FELONY?
ARE YOU AWARE OF FEDERAL MARKETING ORDER NO. 915 THAT GOVERNS THE MARKETING OF AVOCADOS GROWN IN SOUTH FLORIDA?
HAVE YOU READ AND STUDIED THE REQUIREMENTS FOR U.S. GRADE STANDARDS OF AVOCADOS?
DO YOU AGREE TO NOTIFY THIS OFFICE IMMEDIATELY IF THE ANSWER TO ANY OF THE PRECEEDING QUESTIONS CHANGE OVER TIME?
DO YOU UNDERSTAND THE CONDITIONS UNDER WHICH YOUR CERTIFICATE OF REGISTRATION MAY BE SUSPENDED OR REVOKED, AS OUTLINED IN 915.120 IN FEDERAL MARKETING ORDER NO. 915?
CERTIFICATION OF STATEMENT: I (we) hereby agree to comply with all of the requirements of the Marketing Order regulating the handling of avocados grown in the Florida production area and with all the rules and regulations issued thereunder.
SIGNATURE OF APPLICANT		DATE
STATE OF FLORIDA, COUNTY OF _____________________________. Before me the undersigned authority, personally appeared ____________________________________, who, being duly sworn, stated that he (she) is _________________________________ of ______________________________________, and that the statements contained herin are correct to the best of his (her) knowledge and belief. _________________________________________________ NOTARY PUBLIC
NOTE: The making of any false statements or representations in any matter within the jurisdiction of any agency of the United States, knowing it to be false, is a violation of Title 18, Section 1001, United States Code, which provides for a penalty of a fine or imprisonment, or both.

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.

SC-209 (Exp. X/XXXX) Destroy previous editions. Page 3 of 3