Form CAC 100 CAC 100 Citrus Grown in FL. Application for Repacking Certificat

OMB No. 0581-0189

CITRUS ADMINISTRATIVE COMMITTEE

P.O. Box 24508

Lakeland, FL 33802-4508

Phone: (863) 682-3103

Fax: (863) 683-9563

Email: info@citrusadministrativecommittee.org

APPLICATION FOR A REPACKING CERTIFICATE OF PRIVILEGE

20___ - 20___ SEASON

As required by Marketing Order No. 905 regulating the handling of oranges, grapefruit, tangerines, and tangelos grown in Florida

_______________________________________________________________________

Business Name on Citrus Fruit Dealer’s License

Address (incl. City, State, Zip Code)

Phone No.: (_____) __________________________

Fax No.: (_____) __________________________

Hereby certifies and agrees to the following:

1. I (we) have obtained a license as a Citrus Fruit Dealer and request a Certificate of Privilege as a Special Purpose Shipper from the date of this application to ____________________________.

(Citrus Fruit Dealer’s License Number _______________)

2. I (we) will deal only with fruit that has been positive lot identified, inspected and certified, as defined in section 905.53 of Marketing Order No. 905.

3. All citrus fruit handled by me (us) will be from registered packinghouses.

4. I (we) hereby submit a list of suppliers of inspected and certified Florida citrus fruit described in item 2 above, and the approximate number of boxes of Florida citrus fruit that will be handled during the season. (Please attach separate sheet(s) showing supplier’s business name, address, and packinghouse registration number.)

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 OMB 0581-0189. 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.

5. Citrus shipped under a Repacking Certificate of Privilege will:

   1. adhere to the applicable minimum grade and size requirements under Marketing Order No. 905;

   2. be inspected by the Federal-State Inspection Program prior to the time such fruit is received;

   3. be packed in approved Florida Department of Citrus containers; and

   4. be reported to the Committee as required in section 905.163, Reports of Shipments under Repacking Certificate of Privilege.

_______________________________________ _______________________ ____________

Authorized Signature of Licensed Citrus Fruit Dealer Title Date

False certification or knowingly making any false statement to the Secretary of Agriculture is a violation of title 18, section 1001, of the United States Code, and is punishable by fine, imprisonment, or both.

Application for a Repacking Certificate of Privilege

Date: ___________________, 20___

The above “Application for a Repacking Certificate of Privilege” is hereby

□ approved □ disapproved

for the period ____________________, 20___ through _______________________, 20___.

For the 20___-20___ season, you will be Repacking Certificate of Privilege No. ___________.

By: __________________________________________________

Manager, Citrus Administrative Committee

FAILURE TO COMPLY WITH ANY OF THE CONDITIONS STATED IN THIS DOCUMENT IS GROUNDS FOR IMMEDIATE TERMINATION OF THIS CERTIFICATE OF PRIVILEGE.

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.

CAC Form 100 (Exp. X/XXXX) Destroy previous editions. Page 4 of 4