FTC-103 (966) Application for Certified Tomato Repacker (FL. Tom

OMB No. 0581-0178

F

For Office Use Only

Date Received _______

RP Code _______

RP # _______

LORIDA TOMATO COMMITTEE

800 Trafalgar Court, Suite 300  Maitland, FL 32751

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

www.floridatomatoes.org

APPLICATION FOR CERTIFIED TOMATO REPACKER CERTIFICATE

I hereby make application for registration as a Certified Tomato Repacker for the 20___ - 20___ season.

1. Physical address of all location(s) of grading and packing facilities in the regulated area:

2. Type of business (Individual, Firm, Partnership, Corporation, Co-operative, Association, or other business unit): _________________________________________________________________________________

3. 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.

Name	Title	Address, City, State, Zip code

4. How many years has applicant been engaged in the tomato repacking business in Florida? _____________

Business Name of Applicant: ______________________________________________________________

Mailing Address: _______________________________________________________________________

City, State, Zip Code: ____________________________________________________________________

Mailing Address: _______________________________________________________________________

City, State, Zip Code: ____________________________________________________________________

Telephone Number: _______________________ Fax Number: ________________________

Email address: __________________________________________________________________________

By: __________________________________________________ ____________________________________

Authorized Signature Title

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.

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-103 (Rev. 01/2017) Destroy previous editions.