SC-468 Application for License to Sample Processed Foods

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OMB No. 0581-0125

APPLICATION FOR LICENSE TO SAMPLE OR INSPECT FRUITS, VEGETABLES,
NUTS AND MISCELLANEOUS PRODUCTS
In accordance with the Regulations Governing Inspection and Certification of Fruits and Vegetables and Related Products (7 CFR 51 and 52), I hereby apply for a license to sample
and/or inspect products and to certify with respect to the identification, location, kind, grade, condition, or condition of the containers in the lots of such products for applicants
desiring inspection service under the cited regulations.
NAME (LAST, FIRST, M.I.):

ADDRESS:

E-MAIL ADDRESS:

EDUCATION
HIGH SCHOOL:

CITY, STATE:

DATES:

DID YOU GRADUATE?

COLLEGE:

DEGREE:

CITY, STATE:

DATES:

DID YOU GRADUATE?

COLLEGE:

DEGREE:

CITY, STATE:

DATES:

DID YOU GRADUATE?

DEGREE:

EMPLOYERS: PRESENT AND PREVIOUS 3 YEARS
INCLUSIVE DATES

NAME AND ADDRESS OF EMPLOYER

OCCUPATION OR DUTIES

FROM:
TO:

PRESENT

FROM:
TO:
FROM:
TO:
CERTIFICATION
This is to certify that I agree, as a condition to the granting of the license applied for, to faithfully comply with all terms and conditions of the Regulations cited above with respect to
the duties of a licensee of the U.S. Department of Agriculture (USDA). As a licensee of the USDA, I agree to the following:
I will not sample or inspect any lot of products to which I or my employer is an interested party.
To abide by all Federal instructions governing the sampling and inspection of fruits, vegetables, nuts and miscellaneous products, whether given to me in the form of
handbooks, memorandums, written instructions, or personally by the Federal Supervising Inspector to whom I am responsible.
•
In making inspections based on Federal grades, to accept the interpretation of such grades given to me by the Federal Supervising Inspector or other authorized
representatives of the USDA, Agricultural Marketing Service.
•
To make clear and accurate inspection notes, including scoring of grade, defects and other memorandums, of each inspection made by me as shall be directed by the Federal
Supervising Inspector.
•
To prepare my certificates from such notes strictly in accord with Federal instructions.
•
To surrender my license card when so requested by the Federal Supervising Inspector or upon expiration (December 31 next following date of issue), either to him/her or by
mail to the Specialty Crops Inspection Division, Agricultural Marketing Service, U.S. Department of Agriculture, 1400 Independence Ave. SW, Washington, DC 20250.
The statements made by me in this application are true, complete, and correct to the best of my knowledge and belief.
•
•

APPLICATION FILED IN THE STATE OF:

SIGNATURE OF LICENSEE:

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 is 0581-0125. The time required to complete this information collection is estimated to average 10
minutes per response, including the time for reviewing the instruction, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the
collection of information.
SC-468 (6-2017)

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 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.

SC-468 (6-2017)