No Form number (946) WA Potatoes -- Shippers Application for Special Pu

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

SHIPPERS APPLICATION FOR SPECIAL PURPOSE CERTIFICATE

Special Purpose Certificate No. _________________________ Certificate Valid From: _____________

I request permission to ship, grade and/or store and /or sell potatoes for Special Purpose. Under this Special Purpose Certificate number, shipments of potatoes will be made for the following reason(s):

□ Charity □ Prepeeling □ Experimentation ________________

□ Canning, freezing, and/or “other processing”*

□ Grading or storing in Morrow or Umatilla counties (OR)

* “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.”

To the best of your knowledge, please list the names of the companies receiving potato shipments made under this Special Purpose Certificate, also please attach a separate sheet to identify any additional receivers if needed.

Company Name: _______________________________ Contact: ______________________________________ Address: _____________________________________ City/State/Zip Code: ____________________________ Phone: _______________________________________ Fax: _________________________________________ Email: _______________________________________ Purpose: _____________________________________	Company Name: _______________________________ Contact: ______________________________________ Address: _____________________________________ City/State/Zip Code: ____________________________ Phone: _______________________________________ Fax: _________________________________________ Email: _______________________________________ Purpose: _____________________________________
Company Name: _______________________________ Contact: ______________________________________ Address: _____________________________________ City/State/Zip Code: ____________________________ Phone: _______________________________________ Fax: _________________________________________ Email: _______________________________________ Purpose: _____________________________________	Company Name: _______________________________ Contact: ______________________________________ Address: _____________________________________ City/State/Zip Code: ____________________________ Phone: _______________________________________ Fax: _________________________________________ Email: _______________________________________ Purpose: _____________________________________

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.

SHIPPERS APPLICATION FOR SPECIAL PURPOSE CERTIFICATE

In consideration of your granting this permission, I agree to the following stipulations:

1. That all companies/farms are to complete the shipper’s application for special purpose certificates even if a special purpose shipment is not made. If an unexpected shipment is made during the year to a receiver that is not on the original application, I will inform the State of Washington Potato Committee (Committee) in writing to add that receiver to my application. That as each shipment is made under this Special Purpose Certificate, I will prepare a Shipment Report on forms furnished by the Committee and/or recognize that those forms may be submitted by a handler/processor on my behalf. If a Committee form is to be used then one copy will be mailed to the Committee and two copies will be forwarded to the receiver with instructions that the receiver sign one copy and mail it to the Committee and retain the second copy for his files. Failure of the receiver to promptly sign and return the Shipment Report will result in cancellation of permission to ship potatoes under Special Purpose Certificate to this receiver.

2. I certify to the Committee and the Secretary of Agriculture that any shipments made pursuant to this Special Purpose Certificate will be made in accordance with the current Marketing Order regulations. I have read these regulations and I made this application with full knowledge thereof.

COMPANY/FARM NAME: _____________________________________________________________

CONTACT: __________________________________________________________________________

ADDRESS: ___________________________________________________________________________

CITY/STATE/ZIP: ____________________________________________________________________

PHONE: _____________________________________________________________________________

FAX: ________________________________________________________________________________

EMAIL: ______________________________________________________________________________

SIGNATURE: _________________________________________________________________________

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ACTION BY THE ADMINISTRATIVE COMMITTEE FOR MARKETING ORDER NO. 946

Permission is hereby granted/denied the above shipper to ship potatoes for Special Purpose, as defined in the regulations in effect at the time of shipment.

Manager: _________________________________ Date: _________________________________________

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.