WA-302 Examination Report

This form is available electronically.

Form Approved – OMB No. 0581-0305 (See Page 2 for Privacy Act and Paperwork Reduction Act Statements.)

WA-302 U.S. DEPARTMENT OF AGRICULTURE (07-31-18) Agricultural Marketing Service

1. Check One:

Original

EXAMINATION REPORT

Amendment

Subsequent

2. Code No.

3. License No.

4. Amendment No.

5. Date of License (MM-DD-YYYY)

6. Capacity

7. Type of Agreement

     

     

     

     

     

     

8. Name of Warehouse Operator (Legal Entity)      

12. Mailing Address of Headquarters Office (Including ZIP Code) (Include Street Address for Express Delivery)

CHECK

     

 

9. Name of Warehouse

13. Location of Warehouse (City, County or Parish, and State)

 

     

     

10. Mailing Address of Warehouse (Including ZIP Code)

14A. Telephone Number (Area Code)

14B. Fax No.(Area Code)

 

     

     

     

11. Principal Place of Business      

14C. E-Mail Address (If applicable)      

 

15. Individual in Charge (Home Address (Including ZIP Code))

 

     

Telephone Number (Area Code):

     

16. Type of Business Entity: Corporation Partnership Individual LLC

 

17. CORPORATION (Original Examination Only)

A. Charter Expires (Date) (MM-DD-YYYY)

B. Foreign Corporation Permit Issued By

C. Permit Expires (Date) (MM-DD-YYYY)

 

     

State of:      

     

D. Authorized Titles for Signatures

E. Authorized By:

 

Bylaws Resolution

18. CORPORATE OFFICERS

A. President

B. Vice President

C. Vice President

 

     

     

     

D. Vice President

E. Treasurer

F. Secretary

 

     

     

     

19. PARTERSHIP (List names below if not shown above)

A. Type of Partnership (General, limited, etc.)      

 

B.

C.

D.

 

     

     

     

E.

F.

G.

 

     

     

     

20. LIMITED LIABILITY COMPANY

A. Operating Agreement

B. Articles of Organization

C. Authorized Titles for Signatures (If applicable)

D. Authorized By Operating Agreement

Articles of Organization

21. INDIVIDUAL

A. Name

B. Home Address (Including ZIP Code)

 

     

     

Telephone Number (Area Code):

     

WA-302 (07-31-18) Page 2

22. Names of individuals authorized to sign warehouse receipt (Federally licensed houses only):

CHECK

A.

B.

C.

 

     

     

     

D.

E.

F.

 

     

     

     

23. Outstanding licenses issued to inspectors and weighers (Federally licensed houses only):

A. Name of Licensee

B. Service Performed

C. License Number

D. Where Posted

     

     

     

     

 

     

     

     

     

 

     

     

     

     

 

     

     

     

     

 

24. Is all storage space covered by this report included or to be included under license? If “NO”, explain on Form WA-101.

YES NO

25. Is warehouse open at least 6 hours each business day? If “NO”, explain on Form WA-101, the provisions made to receive, deliver, and settle on agricultural products.

YES NO

26. Name of Electronic Warehouse Receipt Provider (If applicable).

     

27. Does Warehouse Operator have any type of agreement with a field warehouse company? If “YES”, has this been cleared with USDA? If “NO”, furnish a copy to Examiner/WCMD.

YES NO

28A. Signature of Examiner

28B. Date (MM-DD-YYYY)

     

NOTE:

The following statement is made in accordance with the Privacy Act of 1974 (5 U.S.C. 552a - as amended).  The authority for requesting the information identified on this form is 7 CFR Part 735, 7 CFR Part 1423, 7 CFR Part 1427, the United States Warehouse Act (Pub. L. 106-472), and the Commodity Credit Corporation Charter Act (15 U.S.C. 714 et seq.). The information will be used to determine whether licensee has required facilities and is operating in accordance with the United States Warehouse Act, regulations, or contractual requirements. The information collected on this form may be disclosed to other Federal, State, Local government agencies, Tribal agencies, and nongovernmental entities that have been authorized access to the information by statute or regulation and/or as described in applicable Routine Uses identified in the System of Records Notice for USDA/FSA-2, Farm Records File (Automated) and USDA/FSA-3, Consultants File.  Providing the requested information is voluntary.  However, failure to furnish the requested information will result in a determination of ineligibility to obtain new licensing or retain existing licensing under the United States Warehouse Act. 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 0581-0305. The time required to complete this information collection is estimated to average 15 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 provisions of appropriate criminal and civil fraud, privacy, and other statutes may be applicable to the information provided. RETURN THIS COMPLETED FORM TO THE WAREHOUSE AND COMMODITY MANAGEMENT DIVISION, STOP 9148, P.O. BOX 419205, KANSAS CITY, MO 64141-6205.

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.