No Form number (948) CO Potatoes (Area III) Certificate of Privilege, S

OMB No. 0581-0178

Colorado Potato Administrative Committee Phone: 970-352-5231

Area III - Northern Colorado Fax: 970-304-0861

P.O. Box 1774

Greeley, CO 80632

APPLICATION FOR CERTIFICATE OF PRIVILEGE FOR SPECIAL PURPOSE SHIPMENT REPORTS

CERTIFICATES OF PRIVILEGE FOR SPECIAL PURPOSE REPORTS are required for the shipment of potatoes for other than fresh market purposes. CHECK THE INTENDED USE FOR WHICH YOUR POTATOES WILL BE SHIPPED.

_______CHIPPING _______CANNING _______FLAKE _______SHOESTRING ________CHARITY

_____OTHER (Please specify_______________________________________________________________________)

It is understood and agreed to by me, the undersigned applicant, that all potatoes granted a Certificate of Privilege for Special Purpose Shipments by virtue of this application and corresponding Special Purpose Shipment Reports must be used for the purpose stated in this application and any deviation or infringement of this privilege which shall become known to me will be reported to the Area III Colorado Potato Administrative Committee (Committee) promptly. Further, that I will not knowingly sell or cause to be sold potatoes which have been granted a Certificate of Privilege and are to be used in violation of said Certificate. I am aware that when Special Purpose Shipment Reports are used for OTHER THAN POTATOES FOR CHIPPING, the RECEIVER must return a copy of the report to the Committee within 15 days.

The Certificate of Privilege/Special Purpose Shipment Reports granted subject to this Application shall be numbered consecutively. All or any part of said Reports not duly executed may be recalled or revoked at the discretion of the Committee and when violation of said application and reports are in evidence. It is agreed that the Committee will be notified of any shipments rejected by receivers of processed potatoes.

False certification, knowing it to be false, is a violation of title 18, section 1001, of the United States Code, among other statures, which provide for a fine, imprisonment, or both.

Approved by Area III ___________________________________ Company Name: ________________________

Date: ________________________________________________ Business Address: ______________________

Forms Issued: City, State, Zip: _________________________

_______________ _______________ ______________ Mailing Address: _______________________

_______________ _______________ ______________ Authorized Signature: ___________________

_______________ _______________ ______________ Certificate of Privilege No. _______________

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 9 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.

State of Colorado MO Docket A-4 (Rev. 01/2017) Destroy previous editions.