OMB No. 0581-0178
F
For
Office Use Only Date
Received _______ RH
Code _______ RH
# _______
800 Trafalgar Court, Suite 300 Maitland, FL 32751
Phone (407) 660-1949 Fax (407) 660-1656
APPLICATION FOR REGISTRATION AS TOMATO HANDLER
I hereby apply for registration as a Tomato Handler for the 20___-20___ season.
Physical address of all location(s) of grading and packing facilities in the production area:
______________________________________________________________________________________
______________________________________________________________________________________
Type of business (Individual, Firm, Partnership, Corporation, Co-operative, Association or other business unit): _________________________________________________________________________________
If other than individual, show below names and addresses of the officers, partners, or other individuals having a financial interest in the business with the applicant.
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Title |
Address, City, State, Zip code |
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How many years have you been in the tomato business in Florida? ___________
Business Name of Applicant: ______________________________________________________________
Street Address: _________________________________________________________________________
City, State, Zip Code: ____________________________________________________________________
Mailing Address: _______________________________________________________________________
City, State, Zip Code: ____________________________________________________________________
Telephone Number: ___________________________ Fax Number: ________________________
Email address: __________________________________________________________________________
By: __________________________________________________ ________________________________
Authorized Signature and Title Print Name
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 0581-0178. The time required to complete this information collection is estimated to average 5 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.
CRITICAL INFORMATION REQUEST
Please provide the information below for each grower who you expect will be shipping through your packing facility for the 20___- 20___ season. This information is needed to ensure that your growers are kept up-to-date on Florida Tomato Committee (Committee) activities and on subjects affecting the Florida tomato industry as a whole, such as: Medfly alerts; government regulations; labor situations; market conditions; etc. Return this form with your application for registration as a tomato handler.
GROWER NAME
CONTACT NAME
ADDRESS
CITY, STATE, ZIP CODE
TEL. NO.
GROWER NAME
CONTACT NAME
ADDRESS
CITY, STATE, ZIP CODE
TEL. NO.
GROWER NAME
CONTACT NAME
ADDRESS
CITY, STATE, ZIP CODE
TEL. NO.
GROWER NAME
CONTACT NAME
ADDRESS
CITY, STATE, ZIP CODE
TEL. NO.
GROWER NAME
CONTACT NAME
ADDRESS
CITY, STATE, ZIP CODE
TEL. NO.
(Make additional copies to list additional growers if necessary.)
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.
FTC-102-75 (Rev. 01/2017). Destroy previous editions.
| File Type | application/msword |
| File Title | September 14, 1998 |
| Author | Sandi Valerio |
| Last Modified By | Pish, Marylin - AMS |
| File Modified | 2017-01-30 |
| File Created | 2017-01-30 |