No Form number (959) So. Texas Onion Committee Certificate of Privilege

OMB No. 0581-0178

SOUTH TEXAS ONION COMMITTEE

901 Business Park Drive, Suite 500 Mission, TX 78572

Phone: (956) 584-9331 Fax: (956) 581-3912

APPLICATION FOR CERTIFICATE OF PRIVILEGE

FOR SPECIAL PURPOSE SHIPMENT REPORTS

Handler Certificate of Privilege No.:

Effective Date: Expiration Date:

Certificates of Privilege for Special Purpose Reports are required for the shipment of onions for other than fresh market purposes.

Purpose of Shipment: □ Canning or Freezing □ Relief or Charity □ Other ______________________

PERSON IN CHARGE OF SPECIAL PURPOSE FORMS: _____________________________________________

WHERE SHIPMENTS WILL ORIGINATE: ________________________________________________________

PLEASE LIST BELOW THE NAMES AND ADDRESSES OF CONSIGNEES YOU PLAN TO SEND SPECIAL PURPOSE ONIONS TO:

Name: __________________________________________ Name: _____________________________________

Name: __________________________________________ Name: _____________________________________

Name: __________________________________________ Name: _____________________________________

I, the undersigned applicant, understand and agree, that all onions granted a Certificate of Privilege for Special Purpose Shipments (Certificate), by virtue of this application and corresponding Special Purpose Shipment Reports, must be used for the purpose stated in this application and any deviation or infringement of this privilege which shall become known to me will be reported to the South Texas Onion Committee (Committee) promptly. Further, I will not knowingly sell or cause to be sold onions which have been granted a Certificate of Privilege and are to be used in violation of Certificate. I acknowledge that making of a false or fraudulent statement for the purpose of influencing the actions of a government agency shall, upon conviction, be subject to a fine or imprisonment, or both (18 U.S.C. 1001).

Company Name Authorized Signature

Mailing Address (Street or Box No., City, State, and Zip Code)

Physical Address (if different than above mailing address)

Telephone Number Fax Number Email Address

FOR OFFICE USE ONLY: COMMITTEE APPROVAL: 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 5 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.

(Exp. x/xxxx) Destroy previous editions.