SC-652 Logo Use Request for Audit Programs

United States
Department of
Agriculture

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OMB No. 0581-0125

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AGRICULTURAL MARKETING SERVICE, SPECIALTY CROPS PROGRAM
LOGO USE REQUEST FOR AUDIT PROGRAMS
FEDERAL AUTHORIZATION: This form is to be completed by authorized personnel in accordance with the specified Specialty Crops
Program audit program(s). All materials which make reference to the audit program(s) design or language are accountable items. Their use is
authorized by a contract between the USDA and the participant company. No materials shall bear reference to the audit program(s) design or
language without prior written consent of the Specialty Crops Program.

A. Logo Description
(GAP&GHP) Audit Program

Type of Logo:

Black
Color**
**(GAP&GHP and IP color logos must use Pantone Matching System
(PMS) color Green 348. PIQ color logos must use the colors red, white
and blue in specified areas. Any other colors used will not be considered
an approved audit program logo and will be in violation of the agreement.)

Identity Preservation (IP) Program
Partners in Quality (PIQ) Audit Program
B. Company Information
___________________________________________
Name of Company

_______________________________________________________________
Mailing Address of Company

___________________________________________
Name and Title of Person Requesting Logo Use

_________________________
Phone Number

____________________________________
Email Address

C. Logo Use
Commodities:_______________________________________________________________________________________________
Select type(s) of use and specify the number of materials that will contain the audit programs logo (Attach Additional Documentation):

Ƒ Containers : ____________
Ƒ Publication(s) ________ type(s):_______________________________________
Ƒ Labels/Stickers ___________
Ƒ Website(s) _________ web address(es):________________________________
Ƒ Other : ____________________________________________________________________________________________________
D. Manufacturer’s Information
___________________________________________

___________________________________________

Manufacturer’s Name

Manufacturer’s Phone Number

_________________________________________________________________________________________
Manufacturer’s Mailing Address

E. Applicant’s Request
As an authorized participant in the Specialty Crops Program audit program(s), I hereby request that the above materials be approved
and produced with the audit program(s) logo. I agree to be responsible for all charges assessed by the manufacturer of the materials
for this order. I also acknowledge that all materials containing the audit program(s) logo are in compliance with the audit program(s)
logo use requirements and are for the exclusive use as a participant in good standing in the audit program(s) as authorized by the
USDA. A copy of the manufacturers’ invoice bearing the exact number of preprinted materials produced with the audit program(s) logo
and a signed copy of Section F will be forwarded to the Specialty Crops Program immediately after the time of receipt.

_______________________________
Applicant’s Signature

_____________

________________________________

____________

Date

Federal Authority Signature

Date

F. Applicant’s Receipt
I have received the above listed materials and they are now my responsibility. I certify that only the materials in the above list have been
produced and will only be used in accordance with an audit program(s) in good standing.

_______________________________
Applicant’s Signature

_____________
Date

________________________________
Federal Authority Signature

____________
Date

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 0581-0125. The time required to complete this information collection is estimated average 20 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.
Non-Discrimination Policy: 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 How to File a Program Discrimination Complaint 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.
SC-652 (6-2017) (Previous editions are to be destroyed)