No Form Number (945) ID/E.OR Potato Committee Application Form for Cons

OMB No. 0581-0178

IDAHO-EASTERN OREGON POTATO COMMITTEE Certificate No.: _______________

3670 South 25^th Street East Effective Date: _______________

Idaho Falls, Idaho 83404 Expiration Date: ______________

Phone: (208) 529-8057/Fax: (866) 672-6425

APPLICATION FOR CERTIFICATE OF PRIVILEGE

FOR SPECIAL PURPOSE SHIPMENT REPORTS

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

CHECK THE INTENDED USE FOR WHICH YOUR POTATOES WILL BE SHIPPED: □ CHIPPING

□ CANNING □ FLAKE □SHOESTRING □CHARITY □OTHER ___________________

CWT To Be Shipped: ____________________________________ Shipment Date: ______________________

Shipment Destination: __________________________________________________________________________

It is understood and agreed to by me, the undersigned applicant, that all potatoes 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 Potato Committee promptly. Further, I will not knowingly sell or cause to be sold potatoes which have been granted a Certificate of Privilege and are to be used in violation of Certificate. I am aware that when Special Purpose Shipment Reports are used, the RECEIVER must return a copy of the report to the Potato Committee within 15 days.

In addition to the penalties provided in 608(c)(14) of the Agricultural Marketing Agreement Act of 1937, as amended, I acknowledge that under title 18, section 1001, of the United States Code, any person who knowingly makes 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.

______________________________________________

Authorized Signature

______________________________________________ ___________________________________

Company Name Approved by Potato Committee

______________________________________________ ___________________________________

Address Date

______________________________________________

City, State, and Zip Code

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 10 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.