FV-36 Special Purpose Shipment Receiver Certification

REPRODUCE LOCALLY. Include form number and date on all reproductions.

OMB No. 0581-0178

IDAHO-EASTERN OREGON ONION COMMITTEE
PO BOX 909, PARMA, ID 83660
PHONE: 208-772-5111 FAX: 208-722-6582
SPECIAL PURPOSE SHIPMENT RECEIVER CERTIFICATION
If you plan to purchase onions grown in the Idaho-Eastern Oregon production area that do not meet fresh
market requirements as stated in 7 CFR § 958.328, and intend them for canning, dehydrating, extracting,
freezing, pickling, and/or experimentation, you must complete and submit this Certificate to the IdahoEastern Oregon Onion Committee (Committee). No shipment of onions for canning, dehydrating,
extracting, freezing, pickling, and/or experimentation may be received from the Idaho-Eastern Oregon
production areas unless this form is completed and returned.
CERTIFICATION STATEMENT:
I, the undersigned, hereby certify to USDA and to the Committee that all onions received at the address
below from the Idaho-Eastern Oregon production area will be used for (check all that apply):
Canning

Dehydrating

Extracting

Freezing

Pickling

Experimentation

I, further certify that none of these onions will be diverted to any fresh market outlet(s) except as
expressly authorized by the Committee. In addition, I agree to submit such documents and reports to the
Committee that may be requested for its auditing purposes. Falsification of information on this
government document may result in a fine or imprisonment, or both (18 U.S.C. 1001).
Signature

Name

Title

Date

Receiver

Phone

Address
City

State

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 05810178. The time required to complete this information collection is estimated to average 2 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.
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.

FV-36 (Rev. 11/2011. Destroy previous editions.)