FTC-108 (966) Florida Tomatoes Application for Certificate of Pr

OMB No. 0581-0178

F

For Office Use Only

Date Received ________

COP Code ________

COP # ________

RH # ________

LORIDA TOMATO COMMITTEE

800 Trafalgar Court, Suite 300  Maitland, FL 32751

Phone (407) 660-1949  Fax (407) 660-1656

www.floridatomatoes.org

20___ - 20___ APPLICATION FOR CERTIFICATE OF PRIVILEGE

Information given in this form is for the use of the Florida Tomato Committee, acting under the authority of the Secretary of Agriculture of the United States (Secretary). Section 966.54 of Marketing Order No. 966 requires that handlers desiring to make shipments of tomatoes for relief, charity, processing, or such other purposes, which may be specified by the Committee, with the approval of the Secretary, shall, prior to making such shipment, apply to the Committee for a Certificate of Privilege. The purpose of such certificate is to safeguard against the entry of such tomatoes into trade channels other than those for which this Certificate of Privilege is granted. REPORTS ON EACH SHIPMENT MUST BE MADE TO THE COMMITTEE ON THE SHIPPING DATE ON FORM FTC-110, REPORT OF SPECIAL PURPOSE SHIPMENT UNDER CERTIFICATE OF PRIVILEGE.

RECEIVERS MUST RETURN THE BLUE COPY TO THE COMMITTEE WITHIN TEN (10) DAYS AFTER RECEIPT. FAILURE TO DO SO MAY RESULT IN THE REVOCATION OF YOUR CERTIFICATE OF PRIVILEGE.

Name of Applicant _____________________________________________________________________________

Address ______________________________________________________________________________________

Purpose of shipment for which Certificate of Privilege is requested _______________________________________

_____________________________________________________________________________________________

Is the applicant registered as a tomato handler with the Committee? □ Yes □ No

If yes, please give Registration No. _____________________________________

To the best of my knowledge and belief, all statements contained in this application are true, correct and complete.

___________________________ _________________________________________________________

Date Name of Firm

__________________________ _________________________________________________________

Telephone Number Signature of Applicant

__________________________ _________________________________________________________

Fax Number Email address

DO NOT WRITE BELOW THIS LINE

Approved □ Disapproved □ Date _____________________________________________________

Signature of Manager/ Compliance Officer of Committee _______________________________________________

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.

20____ - 20____

CERTIFICATE OF PRIVILEGE

This is to certify that ________________________________________________________________________

Mailing Address ____________________________________________________________________________

has complied with the provisions of § 966.54 of the Marketing Agreement and Order regulating the shipment of Florida tomatoes and is authorized to ship tomatoes for the following purpose:

________________________________________________________________________________________

_______________________________________________________________________________________

during the period beginning OCTOBER 10, 20____ and ending JUNE 15, 20____.

All shipments must be certified by the Federal-State Inspection Service and shipping containers must be properly marked.

FLORIDA TOMATO COMMITTEE

________________________________________________

Florida Tomato Committee Manager

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-108 (Rev. 01/2017) Destroy previous editions.