SC-430 Vendor Form

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OMB No. 0581-0125
Exp. 3/31/2023

SPECIALTY CROPS INSPECTION DIVISION
VENDOR FORM
TO BE FILLED OUT BY THE ORIGINATING OFFICE
CHECK ONE: ☐ NEW APPLICANT ☐ UPDATING EXISTING APPLICANT INFORMATION
DATE:

PACA LICENSE NUMBER:

ORIGINATING OFFICE (include office # and state):

APPLICANT NUMBER (IF NEW LEAVE BLANK):

APPLICANT NAME:

CONTACTS:

ADDRESS (STREET ADDRESS REQUIRED):

CITY

STATE:

ZIP:

BILLING ADDRESS (IF DIFFERENT THAN STREET ADDRESS):

CITY:

STATE:

ZIP:

DOING BUSINESS AS (Use this section if certificate recipient is different to the person above):

PHONE:

FAX:

EMAIL:

TAX ID NUMBER (REQUIRED):

☐ SCENARIO A: AN APPLICANT THAT IS NOT LISTED IN THE FEIRS/BIIS GLOBAL LIST OF APPLICANTS.
☐ SCENARIO B: AN APPLICANT THAT IS LISTED IN THE GLOBAL FEIRS/BIIS DATABASE, BUT DOES NOT HAVE AN ACCOUNT NUMBER FOR
THE LOCAL OFFICE.
APPLICANT WILL BE A:
☐

BILLING

DATE SENT TO SERVICE CENTER OR BILLING STAFF:
☐

COD

TO BE FILLED OUT BY SERVICE CENTER OR BILLING STAFF
DATE RECEIVED:

FMMI NUMBER:

APPLICANT NUMBER GENERATED (LIST NUMBER HERE):

NOTES:

DATE ENTERED INTO FEIRS/BIIS & FMMI:

DATE ORIGINATING OFFICE NOTIFIED APP. IS IN FEIRS/BIIS & FMMI:

SC-430 (09/2020)

USDA is an equal opportunity provider, employer, and lender.