SC-237 Record of Request for Inspection/Reinspection of Food Pr

Print

Save

Reset
OMB No. 0581-0125
Exp. 3/31/2023

SPECIALTY CROPS INSPECTION DIVISION
REQUEST FOR INSPECTION
REQUEST FOR:

☐ INSPECTION

☐ REINSPECTION

☐ APPEAL INSPECTION

(This is the only acceptable form for fax or electronic submission to USDA for requesting inspection services)

NOTE: Fill in all appropriate blocks; blocks with “*” must be completed. Inspection may be delayed because of incomplete
information. Type of Inspection must be selected above.
*Applicant’s (Company) Name:

*Date:

*Street Address:

*Time:

*City, State & Zip:

Type of Carrier:

*Contact Person:
*Phone Number:
*E-Mail Address:

☐ Car:
☐ Trailer:
☐ Lot Inspection

*Shipper’s Name:

Enter
when
different
from
Applicant:

Car Number or
License Number:

Type:

City and State:
Receiver’s Name:

Applicant’s P.O. Number:

City and State:
*Location of Product(s):
Lots Separated by (Optional):

*Inspection Requested For (Must select at least one):

☐ PLI Numbers
☐ Grower Numbers

☐ Quality and Condition (including size when applicable)

☐ Size

☐ Size

☐ Condition Only

☐ Other, Specify:
Digital Images Requested:

☐ Net Weight
☐ Yes

☐ No

☐ Other, Specify:
Products To Be Inspected

*Products

Brands/Marks

*Quantity

Type Container

*Size

Type/Variety

Remarks/Special Instructions:

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 0581-0125. The time required to complete this information collection is estimated to average 2
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-237 (9-2020)