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Colorado Potato Administrative Committee					Phone:  970-352-5231
Area III - Northern Colorado 							Fax:  970-304-0861
	P.O. Box 1774
Greeley, CO 80632

AREA III APPLICATION FOR CERTIFICATE OF PRIVILEGE FOR SPECIAL PURPOSE SHIPMENT REPORTS


CERTIFICATES 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 (Please specify_______________________________________________________________________)

It is understood and agreed to by me, the undersigned applicant, that all potatoes granted a Certificate of Privilege for Special Purpose Shipments 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 Area III Colorado Potato Administrative Committee (Committee) promptly.  Further, that 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 said Certificate.  I am aware that when Special Purpose Shipment Reports are used for OTHER THAN POTATOES FOR CHIPPING, the RECEIVER must return a copy of the report to the Committee within 15 days.

The Certificate of Privilege/Special Purpose Shipment Reports granted subject to this Application shall be numbered consecutively.  All or any part of said Reports not duly executed may be recalled or revoked at the discretion of the Committee and when violation of said application and reports are in evidence.  It is agreed that the Committee will be notified of any shipments rejected by receivers of processed potatoes.

False certification, knowing it to be false, is a violation of title 18, section 1001, of the United States Code, among other statures, which provide for a fine, imprisonment, or both.

Approved by Area III ___________________________________	Company Name: ________________________

Date: ________________________________________________	Business Address: ______________________

Forms Issued:						City, State, Zip: _________________________

_______________	_______________	______________	Mailing Address: _______________________
 
_______________	_______________	______________	Authorized Signature: ___________________

_______________	_______________	______________	Certificate of Privilege No. _______________

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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.