APPLICATION FOR REGISTRATION AS AN APPROVED RECEIVER OF SPECIAL PURPOSE SHIPMENTS |

APPLICATION FOR REGISTRATION AS AN APPROVED RECEIVER OF SPECIAL PURPOSE SHIPMENTS (FTC-111)

"*" indicates required fields

The information on this form is kept confidential and used only to monitor shipments.

Name of Supplier (Florida Registered Handler):*

Name of Receiver:*

Receiver Contact Person:*

Receiver Telephone No.*

Fax No.

Receiver Email Address:*

Receiver Address:*

Street Address Address Line 2 City State ZIP Code

Purpose of shipment (Check all applicable):*

Pickling

Processing

Charity or Relief

Export

Experimental Purposes

Other Committee Approved Purpose

Receiver’s physical address where stated privilege purpose is accomplished (i.e. pickling, processing, etc.), if different from above:

Street Address Address Line 2 City State ZIP Code

Does the receiver pack, repack or sell fresh tomatoes?*

Yes

To the best of my knowledge and belief, all statements contained in this application are true, correct and complete. By making this application the receiver agrees that the tomatoes obtained herein will not be resold or transferred for resale, directly or indirectly, but will be used only for the purpose(s) specified above. The receiver further agrees to undergo random inspection and to submit such reports as is required by the Florida Tomato Committee.

Signature of Applicant:*

Authorized Signature

Date

Name of Firm (Receiver):*

Name of Firm (Receiver)

Telephone Number:*

Telephone Number

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 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.

Phone

This field is for validation purposes and should be left unchanged.

FTC-111 (Exp. 3/31/2024)

OMB No. 0581-0178