FGIS-942 Application for Designation

UNITED STATES DEPARTMENT OF AGRICULTURE
GRAIN INSPECTION, PACKERS AND STOCKYARDS ADMINISTRATION
FEDERAL GRAIN INSPECTION SERVICE
COMPLIANCE DIVISION

APPLICATION FOR DESIGNATION
TO PERFORM OFFICIAL FUNCTIONS UNDER THE U.S. GRAIN STANDARDS ACT AS
AMENDED

FORM APPROVED OMB NO. 0580-0013
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 0580-0013. The time required to complete this information
collection is estimated to average 2 hours per response and 1 minute of recordkeeping, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information.
This application must be completed and approved before an individual or government agency may be
considered for designation to perform official functions under the U.S. Grain Standards Act as amended (7
U.S.C. 79).

1. Name of Applicant (Exact name of private firm or state organization):

2. Area (identify the geographic area for which you are applying):

4a. Business location:

5. Telephone number:

3. Scope of Services
Official Inspection

Official Weighing

4b. Business mailing address (if different from 4a):

6. Fax number:

7. Email address:

A separate list may be furnished for the following information
8. Identify below the type of organization; and ownership, if a private agency.
State Organization – List names and titles of all officials (i.e., Commissioner, Director, Division or Bureau Chief, Official Agency Manager).
An organizational chart of the state bureau or department conducting inspection/weighing program should also be submitted.

Corporation – List names of stockholders and percent of ownership of each. List names of officers and directors.

Partnership – List name of partners and percentage of ownership of each partner.
Sole Proprietorship – List name of owner.
Other – Identify type and list ownership. List trustees, if any.

9. Furnish a list of names and mailing addresses (including zip code) of facilities requesting service.

10. Furnish the full address and location of each specified service point, whether it its full-time or applicant-specific, and inspection, weighing, or both.

11. Furnish a list of all non-licensed personnel, including the title of each person. A completed Conflict-of-Interest Questionnaire (Form FGIS – 100) must be
submitted for each non-licensed person listed.

12a. Name and title of Responsible Official:

12b.Name and title of manager or person responsible for the supervision and
management of the grain program. (if different from 12a.)

13. Signature of Responsible Official

14. Date

Form FGIS - 942 (07-04) Previous editions are obsolete. Expires January 2015

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INSTRUCTIONS FOR COMPLETING FORM FGIS - 942 –APPLICATION FOR DESIGNATION
Please type application or print carefully. Additional sheets may be used for any item, if necessary.
(1) Provide the name of the individual, corporation, or state or local governmental agency applying for designation.
(2) Describe the geographic area for which you are applying. If applying for part of an available area for designation, include
boundaries, such as state or county lines, and roads.
(3) Check official inspection, official weighing, or both.
(4a) Provide the applicant’s address, using a street location.
(4b) Provide the applicant’s mailing address, if different from 4a.
(5) Provide the applicant’s telephone number.
(6) Provide the applicant’s telefax.
(7) Provide the applicant’s electronic mail address.
(8) Check either “State Organization”, “Corporation”, “Partnership”, “Sole Proprietorship,” or “Other,” and provide
information requested in that box.
(9) This may be customer billing labels or other attachment.
(10) Supply the full address and location of each specified service point. Indicate for each laboratory if it is open full-time to all
customers, or if it is an applicant specific laboratory for one customer. Indicate what type of facility; whether inspection or
weighing, or both. Describe the types of services to be offered to customers at that location, i.e., inspection, official commercial,
weighing.
(11) List the persons (including their title) not licensed under the U. S. Grain Standards Act, and complete a Form FGIS –100
“Conflict of Interest Questionnaire” for each non-licensed person.
(12a) Type the name and title of the person signing the application.
(12b) Type the name and title of the person responsible for the supervision and management of the grain program, if different
from 12a. Otherwise, leave blank.
(13) The responsible official named in 12a must sign this block.
(14) Provide date signed.
CONTACT INFORMATION:
Submit applications by any of the following methods:
•

Hand Delivery or Courier: Deliver to Chief, Review Branch, Compliance Division, GIPSA, USDA, Room 1647-S, 1400
Independence Avenue, SW., Washington, DC 20250

•

Fax: Send by facsimile transmission to (202) 720-7786, attention: Review Branch

•

E-mail: Send via electronic mail to Samantha.J.Simon@usda.gov

•

Mail: Send to Director, Quality Assurance & Compliance Division, GIPSA, USDA, STOP 3604, 1400 Independence Avenue,
SW., Washington, DC 20250-3604.
For further information contact:
Director
Quality Assurance & Compliance Division
1400 Independence Avenue, SW, Room 2420
Washington, DC 20250
Telephone: (202) 690-3206
Fax: (202) 720-7786
Email: Samantha.J.Simon@usda.gov
GIPSA website: http://www.gipsa.usda.gov