F/H Form D (982) Hazelnuts--Application to be Listed as an Accepted

OMB No. 0581-0178

HAZELNUT MARKETING BOARD

21595-A Dolores Way NE

Aurora, OR 97002-9738

Tel: (503) 678-6823; Fax: (503) 678-6825

APPLICATION TO BE LISTED AS AN ACCEPTED USER OF

INEDIBLE HAZELNUTS AND HAZELNUT WASTE

TO: Hazelnut Marketing Board

An application is made herewith to be listed by the Hazelnut Marketing Board (Board) as an accepted user of inedible hazelnuts and hazelnut waste, and for approval of the use of such material in the outlet(s) checked below:

□ crushing for hazelnut oil

□ mixing into feed

□ feeding directly to livestock or poultry

This will occur at (location): ______________________________________________________________________

Street City

In consideration of the approval of this application, the undersigned agrees that all hazelnut material acquired from hazelnut handlers or growers will be used only for the purposes indicated, that none will be disposed of for human consumption and that Board employees may enter the applicant’s premises at any reasonable time to observe the storage or disposition of the material and to examine and audit the applicant’s transaction records. The undersigned also agrees to obtain from each handler an executed F/H Form ______ on each lot of material received and, upon crushing, mixing or feeding the hazelnuts, to execute part (b) of the form and mail it to the Board.

The undersigned hereby certifies to the U.S. Department of Agriculture and to the Board that the information supplied herein is complete and correct and that the above agreement as to usage and reporting is accepted.

Date ________________, 20_____ __________________________________________________

User Firm

__________________________________________________

Address

__________________________________________________

By

_________________________________________________

Title

Application is hereby approved, subject to revocation for cause:

Date ________________, 20_____ HAZELNUT MARKETING BOARD

__________________________________________________

By

__________________________________________________

Title

The making of any false statement or representation on this form, knowing it to be false, is a violation of title 18, section 1001 of the United States Code, which provides for the penalty of a fine or imprisonment of not more than five years, or both.

No approval can be obtained allowing a user of inedible hazelnuts and waste to make acquisition from a handler until the application form is received (7 U.S.C. 608 (d), 7 C.F.R. 984.64, 7 C.F.R. 984.464).

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 0581-0178. The time required to complete this information collection is estimated to average 20 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.

F/H Form D (Exp. x/xxxx) Destroy previous editions.