CN-383-F HVI Check Test Program - Domestic Order Form

REPRODUCE LOCALLY

FORM APPROVED – OMB NO. 0581-0008

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
COTTON & TOBACCO PROGRAM
DATE
Standardization & Engineering Division
3275 Appling Road
Memphis, TN 38133
Telephone: (901) 384-3030
Fax: (901) 384-3039
E-Mail: cotton.standards@usda.gov

ORDER #
DO NOT WRITE IN THIS SPACE

PAID BY CHECK NO.

AMOUNT

RECEIVED BY

DATE

HVI Check Test Program - Domestic Order Form
P
1
1

ITEM

DESCRIPTION

UNIT PRICE

Complete Program

12 Months

$XXX.XX

Pro-rated Program

1 Month

$XX.XX

First Year Participation

Shipping

Amount based on
destination

Type of HVI Instrument

DOLLAR
AMOUNT

QUANTITY
$

TOTALS

$

The cost of the program to new domestic participants is free the first year, (excluding shipping). After you
return this order form to us, we will notify you of the shipping charges.
The official cost of the program is $XXX.XX for the check test period of August through July . The
$XXX.XX must be paid in advance in U. S. dollars with the check drawn on a U. S. bank, payable to USDA
AMS Cotton and Tobacco Program . If participation starts after August, the cost will be pro-rated at $XX.XX
per month. Payment can also be made by credit card. Letters of credit are not accepted.
CHECK

VISA

MC

ACCT NO.

EXPIRES

SIGNATURE

SHIP TO (print or type)
CONTACT NAME

COMPANY NAME

STREET ADDRESS (necessary)
POSTAL BOX

CITY

PHONE

STATE, COUNTRY AND ZIP CODE

E-MAIL ADDRESS

FAX

CN-383F (Exp. X/XXXX) Destroy previous editions.

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 0581-0008. The time required to complete this
information collection is estimated to average 3 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.
USDA is an equal opportunity provider, employer, and lender.

CN-383F (Exp. X/XXXX) Destroy previous editions.