SC-237 Record of Request for Inspection/Reinspection of Food Pr

FORM APPROVED BY OMB No. 0581-0125

AGRICULTURAL MARKETING SERVICE, SPECIALTY CROPS PROGRAM

REQUEST FOR: INSPECTION REINSPECTION APPEAL INSPECTION

(This is the only acceptable form for fax or electronic submission to USDA for requesting inspection services)

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 0581-0125. 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.

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: program.intake@usda.gov.

USDA is an equal opportunity provider, employer, and lender.

NOTE: Fill in all appropriate blocks; blocks with “*” must be completed. Inspection may be delayed because of incomplete information. Type of Inspection must be selected above.

*Applicant’s (Company) Name:
*Street Address:
*City, State & Zip:
*Contact Person:
*Phone Number:
*E-Mail Address:
Enter when different from Applicant:	*Shipper’s Name:
	City and State:
	Receiver’s Name:
	City and State:
*Location of Product(s):

*Date:

*Time:

Type of Carrier:
Type:	Car Number or License Number:
Car:
Trailer:
Lot Inspection

_{Applicant’s P.O. Number:}

Lots Separated by (Optional):	*Inspection Requested For (Must select at least one):
PLI Numbers	Quality and Condition (including size when applicable)
Grower Numbers	Condition Only
Size	Size
Other, Specify:	Net Weight
Digital Images Requested: Yes No	Other, Specify:

Products To Be Inspected
*PRODUCTS	BRANDS/MARKS	*QUANTITY	Type Container	*Size	Type/Variety

Remarks/Special Instructions;

SC-237 (rev. 06-2016) (Discontinue use of previous editions)