APPLICATION FOR CERTIFICATE OF PRIVILEGE |

APPLICATION FOR CERTIFICATE OF PRIVILEGE (FTC-110)

"*" indicates required fields

Information given in this form is for the use of the Florida Tomato Committee, acting under the authority of the Secretary of Agriculture of the United States (Secretary). Section 966.54 of Marketing Order No. 966 requires that handlers desiring to make shipments of tomatoes for relief, charity, pickling, processing, export, and experimental purposes, or such other purposes, which may be specified by the Committee with the approval of the Secretary, shall, prior to making such shipment, apply to the Committee for a Certificate of Privilege. The purpose of such certificate is to safeguard against the entry of such tomatoes into trade channels other than those for which this Certificate of Privilege is granted.

REPORTS ON EACH SHIPMENT MUST BE MADE TO THE COMMITTEE ON THE SHIPPING DATE ON FORM FTC-110, REPORT OF SPECIAL PURPOSE SHIPMENT UNDER CERTIFICATE OF PRIVILEGE.

RECEIVERS MUST RETURN THE BLUE COPY TO THE COMMITTEE WITHIN TEN (10) DAYS AFTER RECEIPT. FAILURE TO DO SO MAY RESULT IN THE REVOCATION OF YOUR CERTIFICATE OF PRIVILEGE.

Name of Company:*

Address:*

Street Address Address Line 2 City State ZIP Code

Purpose of shipment for which Certificate of Privilege is requested (Check all applicable):*

Pickling

Processing

Charity or Relief

Export

Experimental Purposes

Other Committee Approved Purpose

Is the applicant registered as a tomato handler with the Committee?*

Yes

If yes, please give Registration No.

To the best of my knowledge, all statements contained in this application are true, correct and complete.

Date

Name:*

Name (Print)

Telephone Number:*

Telephone Number

Fax Number:

Fax Number

Email Address:*

Signature of Applicant:*

Authorized Signature

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

Phone

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

FTC-108 (Exp. 3/31/2024)

OMB No. 0581-0178