923-Sweet Cherries Special Purpose Shipment Report

OMB No. 0581-0189

SPSC#______________

WASHINGTON CHERRY MARKETING COMMITTEE

105 S. 18^th STREET, SUITE 205

YAKIMA, WA 98901-2149

TELEPHONE: (509) 453-4837

FAX: (509) 453-4880

SPECIAL PURPOSE SHIPMENT REPORT

To be completed by  SHIPPER or  RECEIVER (please check applicable box):

Name ______________________________________________ Telephone ___________________________

Address __________________________________________________________________________________

(Street, City, State, and Zip Code)

Received from:

Grower/Handler Name (indicate grower or handler)	Sweet Cherry Variety	Pounds

I certify to the Washington Cherry Marketing Committee, the U.S. Department of Agriculture, and the Washington State Department of Agriculture that any shipments made pursuant to this Special Purpose Shipment Certificate will be made in accordance with the current regulations under Marketing Order No. 923, Chapter 16-414 WAC, Cherries, Chapter 16-461 WAC, Inspection Requirements for Fruit and Vegetables, and Chapter 16-463 WAC, Prohibiting the Sale and/or Movement of Infested Cherries. Further, I agree to forward assessments due on these cherries to the Committee office.

Signature _______________________________________ Date _____________________________

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.

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.

(Exp. X/XXXX) Destroy previous editions.