No Form number (946) WA Potato--Application Form for Consideration-Appr

OMB No. 0581-0178

S tate of Washington Potato Committee

P.O. Box 1815, Moses Lake, Washington 98837

Phone (509) 765-8845/FAX (509) 765-4853

POTATO COMMITTEE APPLICATION FORM FOR CONSIDERATION OF APPROVAL

AS A CANNER, FREEZER, SEED, CHARITY, OTHER PROCESSOR, OR PREPEELER OF POTATO PRODUCTS

TO: State of Washington Potato Committee

P.O. Box 1815

Moses Lake, Washington 98837

FROM (Applicant’s Name): _______________________________________________________________________

I/We (Company/Business), __________________________________________________hereby apply to the State of

Washington Potato Committee (Committee) for approval as a “receiver” of potatoes under the Potato Committee’s Special Purpose permit for the purpose of ________________________________________________________________________.

(Canning, freezing, seed, charity, other processing or prepeeling - list one)**

Business/Plant Location(s):______________________________________________________________________________

Expected Suppliers of Potatoes from Washington State: _______________________________________________________

____________________________________________________________________________________________________

I/We hereby certify to the Committee and to the Secretary of Agriculture (Secretary) that potatoes received from the Washington State production area for processing will be used for the purpose stated above, and will not be placed in fresh market channels.

I/We agree to report on shipments received as the Committee may require and the Secretary approve.

The undersigned certifies to the Committee and the Secretary of Agriculture that these potatoes are being used in accordance with current Marketing Order regulations for use only for the purpose stated. The making of a false statement, knowing it to be false, is a violation of title 18, section 1001, of the United States Code, among other statutes which provide for fine and imprisonment.

Address: ___________________________________________________________________________________________

Phone: __________________________________ Email: __________________________________________________

Fax: ____________________________________ Signature: _______________________________________________

** If you list “other processing,” also show the specific use, as other processing is defined. Other processing includes, but is not restricted to, dehydration, chips, shoestrings, starch and flour. It includes the application of heat or cold to such an extent that the natural form or stability of the commodity undergoes a substantial change. The act of prepeeling, cooling, slicing, dicing or applying material to prevent oxidation does not constitute “other processing.”

****************************************************************************************************

Permission is hereby granted/denied the above company to be added to the approved list of Special Purpose Receivers.

Manager: __________________________________________________ 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 OMB 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.