CAC 401 905 Citrus Grown in FL Grower Tree Run Certificate Appli

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 GROWER TREE RUN CERTIFICATE

20___ - 20___ SEASON

Name of Grower

Address (incl. City, State, Zip Code

Phone No. (_____) ___________________________ Fax No. (_____) ___________________________

E-mail Address

Hereby certifies and agrees to the following:

1. All citrus fruit handled by me will be from my grove(s), and is subject to Florida statute chapter 601.9911 and 7 CFR 301.75.

2. Legal description of my grove(s):
   
   

3. Variety of citrus produced on the above listed grove(s):
   
   

4. Approximate number of boxes produced on the above identified grove(s):
   
   

5. All citrus fruit handled by me will be reported to the Citrus Administrative Committee as required in 7 CFR 905.149, Reports of Shipments under Grower Tree Run Certificate.
   
   

6. Each container must be identified by name and address, and any other information required by 7 CFR 301.75.

________________________________________________________ ____________________________

Grower Signature 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.

The above application for a Grower Certificate is hereby approved/disapproved (circle one) for the period through July 31, 20___. For the 20___ - 20___ season, you will be Grower Tree Run Certificate No. ________________.

________________________________________________________ ____________________________

Manager, Citrus Administrative Committee Date

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

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.

CAC Form 401 (Exp. X/XXXX) Destroy previous editions.