CN-383-K Micronaire Orifice Calibration Material Order Form

REPRODUCE LOCALLY

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
COTTON AND TOBACCO PROGRAM
DATE:

ORDER #

DO NOT WRITE IN THIS SPACE
PAID BY CHECK NO.
AMOUNT

Standardization & Engineering Division
3275 Appling Rd.
Memphis, TN 38133
Telephone: (901) 384-3030
Fax: (901) 384-3032
E-mail: cotton.standards@ams.usda.gov

RECEIVED BY

DATE

Micronaire Orifice Calibration Material Order Form
ITEM

U.S.

Micronaire Orifice Set

J1

Storage Box, 10 gram brass weight, and
Low & High Orifice Plugs

J2

Low Micronaire Orifice Plug

J3

High Micronaire Orifice Plug

J4

Reassignment of Micronaire Orifice Set
(Requires the return of orifice set)

Micronaire Orifice Storage Box

J5
S1

Includes 10 gram brass weight

Micronaire Chamber Calibration Cotton

FOB Memphis

$XXX.XX

Surface Delivery

$XXX.XX

FOB Memphis

$XX.XX

Surface Delivery

$XX.XX

FOB Memphis

$XX.XX

Surface Delivery

$XX.XX

FOB Memphis

$XX.XX

Surface Delivery

$XX.XX

FOB Memphis

$XX.XX

Surface Delivery

$XX.XX

FOB Memphis
Surface Delivery

(5 lbs.)

EXPORT

QUANTITY

Request Quote for
Air Freight Pre-Paid

DOLLAR
AMOUNT
$

Request Quote for
Air Freight Pre-Paid
Request Quote for
Air Freight Pre-Paid
Request Quote for
Air Freight Pre-Paid
Request Quote for
Air Freight Pre-Paid

$XX.XX

Request Quote for
Air Freight Pre-Paid

$XXX.XX

Totals

$

PAYMENT MUST BE SUBMITTED WITH ORDER. WE DO NOT ACCEPT LETTERS OF CREDIT.
CHECK MUST BE DRAWN ON A U.S. BANK PAYABLE TO : USDA, AMS, COTTON AND TOBACCO PROGRAM.
CHECK

VISA

MC

ACCT. NO.

EXPIRES

SIGNATURE

PRICES: Price of standards includes packaging, handling and delivery where stated. Fumigation (if needed) is a minimum of $XX.XX per order.
Phytosanitary Certificate (if needed) is $XX.XX.

SHIP TO (print or type)
CONTACT NAME

COMPANY NAME

STREET ADDRESS (necessary)
POSTAL BOX

CITY

PHONE

STATE, COUNTRY, AND ZIP CODE

E-MAIL ADDRESS

FAX

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 0581-0008. The time
required to complete this information collection is estimated to average 3 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.
CN-383-K (12-06)