Form PPQ Form 621 PPQ Form 621 Application for General Permit to Engage in the Business

Clear Form
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 0579-0076. The time
required to complete this information collection is estimated to average 1 hour 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.

OMB APPROVED
0579-0076
EXP: 02/2022

MAIL COMPLETED APPLICATION WITH CHECK
TO:

U.S. DEPARTMENT OF AGRICULTURE
ANIMAL AND PLANT HEALTH INSPECTION SERVICE
PLANT PROTECTION AND QUARANTINE

APPLICATION FOR PROTECTED PLANT PERMIT TO ENGAGE IN THE BUSINESS OF
IMPORTING, EXPORTING, OR RE-EXPORTING TERRESTRIAL PLANTS
REGULATED BY 50 CFR 17.12 AND 23.23

USDA-APHIS-PPQ-Permit Unit
4700 River Road, Unit 136
Riverdale, Maryland 20737-1236
(877) 770-5990

INSTRUCTIONS: One copy of this application must be accompanied by a check or money order for $70.00 made payable to: Plant Protection and
Quarantine. In addition, if you are importing wood products, regulated under 7 CFR 319.40, please complete PPQ Form 585. If you are importing
regulated plant material, please complete PPQ Form 587 in addition to this form.
1. NAME AND UNITED STATES ADDRESS OF APPLICANT

2. NAME OF BUSINESS
3. TELEPHONE NUMBER
4. FAX NUMBER
5. EMAIL ADDRESS

6. FORM OF BUSINESS ("X" one If applying as a business)
Corporation
Firm
Partnership
Other (specify)
6(a). DESCRIBE THE NATURE OF YOUR ACTIVITIES RELATING TO IMPORTING, EXPORTING, OR RE-EXPORTING PLANTS REGULATED BY
50 CFR 17.12 and 23.23

6(b). LIST THE NAME AND ADDRESS OF EACH PARTNER, OFFICER, DIRECTOR, HOLDER, AND OWNER OF 10% OR MORE OF VOTING
STOCK, AND EMPLOYEE IN MANAGERIAL OR EXECUTIVE CAPACITY (continue on the back of the form if additional space is needed)

7. ADDRESS(ES) WHERE PLANTS REGULATED BY 50 CFR 17.12 AND 23.23 WOULD BE GROWN OR STORED AND ANY OTHER LOCATION
WHERE ACTIVITIES RELATED TO SUCH PLANTS WOULD BE CONDUCTED

8. STREET ADDRESS WHERE BOOKS OR RECORDS CONCERNING
THE IMPORTATING, EXPORTATING OR RE-EXPORTING OF PLANTS
REGULATED BY 50 CFR 17.12 AND 23.23 WILL BE KEPT

9. NAME AND ADDRESS OF THE PERSON AUTHORIZED TO MAKE
RECORDS OR PLANT INVENTORIES AVAILABLE FOR EXAMINATION
BY INSPECTORS

TELEPHONE NUMBER (Include Area Code):

I hereby certify that the information in this application Is complete and accurate to the best of my knowledge and belief. WARNING: Any alteration, forgery,
or unauthorized use of this document is subject to civil penalties of up to $250,000 (7 U.S.C. 7734(b)) or punishable by a fine of not more than $10,000, or
imprisonment of not more than 5 years, or both (18 U.S.C. 1001) for false statement.
11. DATE
10. SIGNATURE (applicant or partner if a business) :

PPQ FORM 621
JAN 2014

Previous edition is obsolete.