CAC 200 905 Citrus Grown in FL. Application for Certificate of P

OMB No. 0581-0189

CITRUS ADMINISTRATIVE COMMITTEE
PO Box 941058
Maitland, FL 32794
Phone: (321)-214-5252 or (407) 765-5940
peter@citrusadministrativecommittee.org
APPLICATION FOR A CERTIFICATE OF PRIVILEGE BY A SPECIAL PURPOSE SHIPPER
As required by Marketing Order No. 905 regulating the handling of oranges, grapefruit, tangerines, and
tangelos grown in Florida
_______________________________________________________________________
Business name on Citrus Fruit Dealer’s License
Address (incl. City, State, Zip Code)__________________________________________________________________
____________________________________________________________________________________________
Phone No.: (____) _______________________

Fax No.: (____) _________________________

Hereby certifies and agrees to the following:
1.

I (we) have obtained a license as a Citrus Fruit Dealer and request a Certificate of Privilege as a Special
Purpose Shipper from the date of this application to _______________________, 20___.
(Citrus Fruit Dealer’s License Number _______________)

2.

All citrus fruit handled by me (us) will be produced on grove properties certified as organic. List certifying
organization, number, expiration date, location of property and varieties produced. If additional space is
needed, attach this information to this application.
Certifying Organization: _____________________________________________________________
Certification Number: _____________________________ Expiration Date: ____________________
Location of grove:__________________________________________________________________
Variety or varieties of citrus fruit: ______________________________________________________

3.

Citrus shipped under a Certificate of Privilege will:
a. adhere to the applicable minimum grade and size requirements under Marketing Order No. 905;
b. be inspected by the Federal-State Inspection Program prior to the time such fruit is shipped; and
c. be reported to the Committee as required in section 905.148, Reports of Special Purpose
Shipments.

4.

I (we) will make no claims, written or verbal, concerning any alleged advantages of using, or any alleged
superiority of, citrus fruit shipped under a Certificate of Privilege, compared to other Florida produced
citrus.

5.

If this application is approved, I (we) clearly understand that it in no way represents an endorsement by the
Citrus Administrative Committee, and agree that I (we) will not in any way use, or make reference to the
Citrus Administrative Committee’s approval in any advertising, mail distribution, signs, letterhead or in
any other manner whatsoever.

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 OMB
0581-0189. 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.

CAC Form 200 (Rev. 12/2018. Destroy previous editions.)

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OMB No. 0581-0189

I (we) certify to the Citrus Administrative Committee and the Secretary of Agriculture that this fruit is shipped in
accordance with the current Marketing Order regulations. I (we) realize that the making of a false statement,
knowing it to be false is a violation of title 18, section 1001, of the United States Code, among other statutes, which
provide for fine and imprisonment.
_____________________________________________
Authorized Signature of Licensed Citrus Fruit Dealer

____________________
Title

_____________
Date

Application for a Certificate of Privilege by a Special Purpose Shipper
Date: __________________________________ 20, ___
This certificate number _________________ for a Certificate of Privilege as a Special Purpose Shipper is
hereby approved for the period ___________________, 20___ through _____________________, 20___.

By:__________________________________________________
Manager, Citrus Administrative Committee
FAILURE TO COMPLY WITH ANY OF THE CONDITIONS STATED IN THIS DOCUMENT IS
GROUNDS FOR IMMEDIATE TERMINATION OF THIS CERTIFICATE OF PRIVILEGE.

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.

CAC Form 200 (Rev. 12/2018. Destroy previous editions.)

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