Form SC-380 Order Form for Equipment and Miscellaneous Items

OMB No. 0581-0292

SPECIALTY CROPS PROGRAM
SPECIALTY CROPS INSPECTION DIVISION
ORDER FORM FOR EQUIPMENT AND MISCELLANEOUS ITEMS
Complete form, call 650-552-9073 for shipping cost, total all items and email, fax, or mail to:
USDA, AMS, SCP, SCI Division, Equipment & Forms Depot, 831 Mitten Road, Room 200, Burlingame, CA 94010
Phone: 650-552-9073  Fax: 650-552-9147  Email: [email protected]
Bill to:

Ship to:

Name:

Name:

Company:

Company:

Address:

Address:

City, State, Zip:

City, State, Zip:

Phone:

Fax:

Phone:

Fax:

Item Description

Quantity

Price Per Item

Total Cost

Subtotal
Check here for overnight delivery (additional charges apply)

Shipping
Total

Payment Information (all international and first-time customers must pay with a credit card):
Check enclosed (Payable to: USDA-AMS)
Visa
MasterCard
Card Number:

American Express
Expiration Date:

Discover
CVV Code:

Mailing Address for Card:
Name on Card:

Signature:
Products not sold by USDA should be ordered directly from the manufacturer.

For Internal Use:
Industry

Federal

Federal-State

Check

Credit

FV-218 Reimbursement

Invoice

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 is 0581-0292. The time required to complete this information collection is estimated to average five
minutes per response, including the time for reviewing the instruction, searching existing data sources, gathering and maintaining 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
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-380 (6-2017)