TM-10CG Application for Accreditation

REPRODUCE LOCALLY. Include form number and edition date on all reproductions.
FORM APPROVED – OMB NO. 0581-0191
Please send electronic version to: AIAInbox@ usda.gov OR mail paper version
U.S. DEPARTMENT OFAGRICULTURE
to:
AGRICULTURAL MARKETINGSERVICE
National Organic Program c/o Accreditation Division
1400 Independence Ave., SW, Room 2648 So., Ag Stop 0268
APPLICATION FOR ACCREDITATION
Washington, DC 20250-0268
NOTE: The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 522a) and the Paperwork Reduction Act of 1995, as amended. The authority
for requesting this information to be supplied on this form is the Agricultural Marketing Agreement Act of 1937, Secs. 1-19, 48 Stat. 31, as amended, (7 U.S.C. 601-674).
Furnishing the requested information is necessary for the administration of this program. Submission of the Tax identification Number (TIN) or Employer Identification
Number (EIN) is mandatory, and will be used to determine affiliation or entity identity. Please note that background statements will not become invalid if a TIN or EIN is
not disclosed.
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 0581-0191. The time required to complete this information
collection is estimated to average 93.75 hours per initial response and 1 hour per five-year accreditation cycle for certifiers renewing their accreditations; including the
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where
applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an
individual’s income is derived from any public assistance program (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means
for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). To file a
complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272
(voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.
The undersigned hereby applies for accreditation to the National Organic Program, U.S. Department of Agriculture.
Business Name, Mailing Address, and Primary Office Location (if different)
Name of person responsible for day-to-day operations:
Title of person responsible for day-to-day operations:
Tax ID#
E-mail address:

Telephone Number:
Fax Number:

PLEASE ESTIMATE THE ANNUAL ANTICIPATED NUMBER OF CERTIFICATIONS FOR EACH TYPE OF ACCREDITATION
CROPS
LIVESTOCK
WILD CROP
HANDLING
LEGAL STATUS (Check one)
FOR-PROFIT
NOT FOR PROFIT
GOVERNMENT
OTHER (Specify)
BUSINESS
BUSINESS
I, (We), affirm that, if granted accreditation, I (we) will carry out the provisions of 7 CFR Part 205, including the requirements of 7 CFR Part 205.501 General
Requirements for Accreditation.
SIGNATURE OF APPLICANT OR REPRESENTATIVE

PRINT OR TYPE NAME OF SIGNEE

TITLE OF APPLICANT OR REPRESENTATIVE

DATE

FOR APPLICANTS FOR ACCREDITATION, PLEASE ATTACH: 1) A list of each organizational unit, such as chapters or a subsidiary office
including the name, office location, mailing address, and contact numbers (telephone, facsimile, and Internet address), and the name of a contact person
for each unit; 2) A copy of the fee schedule for all services to be provided under these regulations by the applicant; 3) For a government entity, a copy
of the official’s authority to conduct certification services under 7 CFR Part 205; 4) For a private entity, documentation showing the entity’s status and
organizational purpose, such as articles of incorporation and by-laws or ownership or membership provisions, and it’s date of establishment; 5) A list of
each State or foreign country in which the applicant currently certifies production and handling operations and a list of each State or foreign country in
which the applicant intends to certify production and handling operations; 6) The requirements of 7 CFR Part 205, § 205.504, Evidence of expertise
and ability.
FOR CERTIFIERS WHO HAVE HAD THEIR ACCREDITATION SUSPENDED AND ARE APPLYING TO HAVE THEIR
ACCREDITATION REINSTATED, PLEASE ATTACH: The aforementioned six items for applicants for accreditation as well as documentary
evidence that the applicant has corrected previously cited noncompliances, is in compliance with the regulations and is capable of remaining in
compliance.
FOR USDA-ACCREDITED CERTIFIERS RENEWING THEIR ACCREDITATION, DO NOT ATTACH ANY OTHER
DOCUMENTATION WHEN SUBMITTING THIS FORM. THE NOP WILL REQUEST THIS INFORMATION AFTER SCHEDULING
YOUR RENEWAL ASSESSMENT.
FOR USE BY USDA
DATE OF RECEIPT

TM-10CG (10-13)

Expires xx/xxxx

NAME OF RECIPIENT

SIGNATURE OF RECIPIENT