SC-430 Vendor Form

OMB No. 0851-0125

SPECIALTY CROPS INSPECTION DIVISION
VENDOR FORM
TO BE FILLED OUT BY THE ORIGINATING OFFICE / APPLICANT
CHECK ONE: ☐ NEW APPLICANT ☐ UPDATING EXISTING APPLICANT INFORMATION
DATE:

PACA LICENSE NUMBER:

ORIGINATING OFFICE (include office # and state):

APPLICANT NUMBER (IF NEW LEAVE BLANK):

APPLICANT NAME:

CONTACTS:

ADDRESS (STREET ADDRESS REQUIRED):

CITY:

STATE:

ZIP:

BILLING ADDRESS (IF DIFFERENT THAN STREET ADDRESS):

CITY:

STATE:

ZIP:

DOING BUSINESS AS (Use this section if certificate recipient is different to the person above):

PHONE:

FAX:

EMAIL:

TAX ID NUMBER (REQUIRED):

☐ SCENARIO A: AN APPLICANT THAT IS NOT LISTED IN THE FEIRS/BIIS GLOBAL LIST OF APPLICANTS.
☐ SCENARIO B: AN APPLICANT THAT IS LISTED IN THE GLOBAL FEIRS/BIIS DATABASE, BUT DOES NOT HAVE AN ACCOUNT NUMBER FOR
THE LOCAL OFFICE.
APPLICANT WILL BE A:
☐ BILLING

DATE SENT TO SERVICE CENTER OR BILLING STAFF:
☐ COD
TO BE FILLED OUT BY SERVICE CENTER OR BILLING STAFF

DATE RECEIVED:

FMMI NUMBER:

APPLICANT NUMBER GENERATED (LIST NUMBER HERE):

NOTES:

DATE ENTERED INTO FEIRS/BIIS & FMMI:

DATE ORIGINATING OFFICE NOTIFIED APP. IS IN FEIRS/BIIS & FMMI:

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 0581-0143. The time required to complete this information collection is estimated to average 18 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.
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-430

USDA is an equal opportunity provider, employer, and lender.