CN-246 Application for License to Sample Cotton under the Unite

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REPRODUCE LOCALLY. Include form number and edition date on all reproductions.

OMB APPROVED - NO. 0581-0008

This application is authorized by law, 7 U.S.C. 51 et. seq. (U.S. Cotton Standards Act) and U.S.C. 473 c et. seq. (Smith-Doxey Act) and the regulations issued
thereunder (7 CFR Part 28). Furnishing the information is voluntary and no penalty will be imposed for failure to respond; however, this information is
necessary if we are to issue the license.

U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
COTTON AND TOBACCO PROGRAM

APPLICATION FOR LICENSE
TO SAMPLE COTTON
UNDER THE
UNITED STATES
COTTON STANDARDS ACT

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 0581-0008. 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.

INSTRUCTIONS: Answer all questions and send one completed application to the address shown at the bottom of the page. A company operating more than one
warehouse or gin may submit one application for all warehouses or gins. However, the name, location, and mailing address of each warehouse or gin to be licensed should
be listed on Page 2. A separate license will be issued for each warehouse or gin.
1.

2. TYPE OF BUSINESS FOR WHICH
APPLICATION IS BEIING MADE:

NAME IN WHICH BUSINESS IS CONDUCTED (Print or type):

(Mark an "X" in appropriate block):

COTTON GIN COTTON
WAREHOUSE
3.

LOCATION OF BUSINESS (Street and number, City State, and Zip Code):

4.

MAILING ADDRESS (Street or P.O. Box Number, City, State, and ZIP Code):

5. NUMBER OF WAREHOUSES OR GINS
OPERATED

Enter your E-Mail address here:
6. BUSINESS IS (Mark an "X" in appropriate block):
OWNED BY ONE PERSON

A CORPORATION

A PARTNERSHIP

AN ASSOCIATION

7. IF THIS APPLICATION IS FOR A
WAREHOUSE, IS COTTON STORED FOR
THE PUBLIC
YES

NO

CERTIFICATION STATEMENT: The undersigned, as a condition to the granting of the license, agrees to comply with and
abide by the terms of the United States Cotton Standards Act and Regulations. The statements made in the foregoing application
are hereby certified to be true to the best of the knowledge and belief of the undersigned.
NOTE: Application must be signed by the owner or a responsible official of the warehouse or gin.
If submitted electronically, type your name in the signature block.
SIGNATURE

SUBMIT ELECTRONICALLY OR MAIL TO:

TITLE

DATE

FOR USE BY COTTON PROGRAMS
DATE LICENSE ISSUED

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------LICENSE NUMBER

CN-246 (Exp. X/XXXX) Destroy previous editions.

REPRODUCE LOCALLY. Include form number and edition date on all reproductions.

OMB APPROVED – No. 0581-0008

APPLICATION FOR LICENSE TO SAMPLE COTTON
UNDER THE UNITED STATES COTTON STANDARDS ACT
INSTRUCTIONS: This page should be used to provide additional names, locations and mailing addresses
of warehouses or gins to be licensed.
NAME IN WHICH BUSINESS IS CONDUCTED

NAME OF OWNER OR RESPONSIBLE OFFICIAL

NAME, LOCATION, AND MAILING ADDRESS (If Different) OF ADDITIONAL WAREHOUSES OR GINS (Street or P.O.
Box Number, City, State, and Zip Code)

NAME IN WHICH BUSINESS IS CONDUCTED

NAME OF OWNER OR RESPONSIBLE OFFICIAL

NAME, LOCATION, AND MAILING ADDRESS (If Different) OF ADDITIONAL WAREHOUSES OR GINS (Street or P.O.
Box Number, City, State, and Zip Code)

NAME IN WHICH BUSINESS IS CONDUCTED

NAME OF OWNER OR RESPONSIBLE OFFICIAL

NAME, LOCATION, AND MAILING ADDRESS (If Different) OF ADDITIONAL WAREHOUSES OR GINS (Street or P.O.
Box Number, City, State, and Zip Code)

Page 2

CN-246 (Exp. X/XXXX) Destroy previous editions.

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