Form FV-211 Application for License

UNITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

APPLICATION FOR LICENSE

_{(Under the Perishable Agricultural Commodities Act, 1930)}

OMB Approved - 0581-0031

For questions call (800) 495-7222 ext 1 or email: PACALicense@ams.usda.gov PACA Website:

http://www.ams.usda.gov/paca

The information requested on this form is required under the Perishable Agricultural Commodities Act (7 CFR 46.4) for the issuance of a license. The information contained in this form will be used by Federal, State, local, or foreign agencies when relevant to civil, criminal, or regulatory investigations or procedures. Failure to provide the information required will result in delay or suspension of the processing of this form.

ALL QUESTIONS MUST BE ANSWERED
1a. Name of Business (Full Legal Name of Business registered under EIN)		1b. If Sole Proprietor, enter Owners Full Name
2. Federal Employer Identification Number (EIN)	3. Web Site

_{4a. Physical Business Address (Post Office Box NOT ACCEPTABLE)}

Street Address
City	State	Zip Code+4
Telephone Number (With Area Code)	Fax Number (With Area Code)	E-Mail Address

4b. Mailing Address (Mark an “X” here if same as Business Address):

Street Address (Post Office Box Number) Attention:

City _{State Zip Code+4}

5a. Does the business have any branch locations other than your physical business address?

Yes

_No

How many?

5b. Does the business have additional trade names? Yes No

_{5c. Please list Trade Names and/or Branch Locations Below. (Attach a separate page for additional entries)}

	Trade Name		City		State
6a. Legal Structure (see page 4 for explanations) (CHECK ONE BOX ONLY) Sole Proprietor Corporation (see 6b) Limited Liability Company (LLC) (see 6b and 6c) Partnership Limited Partnership Limited Liability Partnership (LLP) Association Trust Estate		6b. Complete only if you checked Corporation or LLC
			State	Date of Incorporation/Organization
				Month Day Year
		6c. Complete only if you checked LLC Articles of Organization is included with application Operating Agreement is included with application
		8. Primary Nature of Business: (see page 4 for explanations) (CHECK ONE BOX ONLY) Broker Processor Retailer Commission Merchant Shipper Grocery Wholesal Food Service Trucker Grower Wholesaler Growers' Agent
7. Types of Fruits and Vegetables Handled by Applicant (CHECK ONE BOX ONLY) Fresh Frozen Fresh and Frozen

_er

FV-211 (06-13)

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9. List below the required information for Individual Owner; All Partners; All Members and/or Managers of LLCs; All Officers (Including Titles), Directors, and/or Stockholders holding more than 10 percent of outstanding voting stock. If any person listed is a minor, furnish the name of His/Her guardian. If any person listed is a trust, furnish the name of the trustee. If any person listed is an estate, furnish the name of the Executor/Executrix.

_{(Attach a separate page for additional entries)}

Name Last Name (Print on First Line) First Name and Middle Initial	Social Security Number	Home Address First Line - Number and Street Second Line - City, State, and ZIP Code (Post Office Box NOT ACCEPTABLE)	Title (Including Director)	Percentage of Stock or Ownership
Smith	123-45-7890	123 Main Street	President	75%
John A.		Anytown, DC 12345-7890

10. Has the applicant or any person listed in Question 9 filed bankruptcy, been discharged as a bankrupt, or been an officer, director, shareholder, partner, member/manager (LLC), or owner of a firm that has filed bankruptcy or been discharged as bankrupt?

Yes No

If Yes, identify the firm or individual (PACA license number, if possible), the name and address of the firm involved, and details about bankruptcy. Submit a copy of the bankruptcy petition, schedules, disclosure statements, and all other relevant documentation. (Attach a separate sheet for additional space)

_{11. Has any person listed in Question 9 been convicted of a felony in any State or Federal Court?}

Yes No

If Yes, furnish the name, date of birth, and alias (if any), of the individual(s). FOR ALL CONVICTIONS, provide the name and location of the court, date convicted, nature of the felony, sentence imposed, where served; if paroled, give date terminated or will terminate. (Attach a separate sheet for additional space)

12. Has any person currently employed by the applicant been the individual owner, partner, officer, director, or holder of more than 10 percent of the outstanding voting stock of a firm, association, or corporation, or a member/ manager (LLC) whose PACA license is under suspension; been revoked; found to have committed any flagrant or repeated violation of the PACA, or against which there is an outstanding unpaid reparation award?

Yes No

If Yes, furnish the full name of the person, name of the firm involved (PACA License number if possible), and details of such connection, including the dates thereof. (Attach a separate sheet for additional space)

Signature(s):	Date:

13. Is the applicant currently operating at volumes requiring a PACA License? (See Page 4 for Nature of

_Business)

Yes No If Yes, provide the date applicant first met that volume.

^{Month Day} Year

	SCHEDULE A Applicants - Wholesalers, Brokers, Commission Merchants, Food Service, Growers, Grower’s Agent, Processors, and Shippers.
(A1) Current License Fees Annual License Fee $ 995.00 Branch Fee, if applicable: $600.00 X branches (maximum of $7,005) $ TOTAL AMOUNT DUE FOR CURRENT FEES (A1) $ (A2) Accrued fees for previous operations based on the date provided in question 13. (Maximum of 24 months) October 1, 2010 to Present Annual License Fee = $82.92 per month X months $ Annual Branch Fee = $50.00 per month X months X branches $ Prior to October 1, 2010 Annual License Fee = $45.83 per month X months $ Annual Branch Fee = $16.67 per month X months X branches $ TOTAL AMOUNT DUE FOR PREVIOUS OPERATIONS (A2) $ TOTAL AMOUNT DUE FOR CURRENT (A1) & PREVIOUS OPERATIONS (A2) $
SCHEDULE B Applicants - Retailers and Grocery Wholesalers ONLY (all others use Schedule A) TOTAL AMOUNT DUE $100
PAYMENT TOTAL AMOUNT DUE $ CHECKS: Make payable to USDA - PACA CREDIT CARDS: Type of Card: VISA MASTERCARD DISCOVER AMERICAN EXPRESS Account Number: Exp. Date: Mo: Year Card Holder’s Name: If Paying Fees by Credit Card, completed application can be faxed to (703) 330-4555 or email PACALicense@ams.usda.gov.		Application must be signed by the Owner, all Partners, all General Partners, Member/Manager (LLC) or a Corporate Officer. CERTIFICATION STATEMENT I (We) certify that the answers given to the foregoing questions are true to the best of my (our) knowledge. Applicant agrees not to loan or transfer possession of the license certificate to any person or firm whatsoever. RETURN COMPLETED APPLICATION AND FEES TO: USDA, PACA Branch, National License Center 8700 Centreville Road, Suite 206 Manassas, VA 20110-8411

_{DEFINITIONS AND TERMS}

Dealer (includes wholesalers, jobbers, distributors, and growers who market produce grown by others) means any person engaged in the business of buying or selling in wholesale or jobbing quantities, as defined by the Secretary, any perishable agricultural commodity in interstate or foreign commerce. A person who buys potatoes for canning or processing is a dealer whether the potatoes are purchased within the state or in interstate or foreign commerce.

Interstate or Foreign Commerce means all transactions involving fresh and frozen fruits and vegetables which move between states, and/or other countries and the U.S.

Wholesale or Jobbing Quantities means aggregate quantities of all types of produce totaling one ton (2,000 pounds) or more in weight in any day shipped, received, or contracted to be shipped or received

Branch or Additional Business Facility means an office or outlet in a location other than that of the principal or main office of a firm, out of which or through which the firm purchases, sells, negotiates contracts, solicits, or handles consignments, or otherwise contracts in perishable agricultural commodities including seasonal, part-time and full-time operations.

_{NATURE OF BUSINESS: (See Question 8) LEGAL STRUCTURES: (See Question 6a)}

The following are definitions of the types of dealers, brokers and commission merchants that are required to have a PACA license.

Wholesaler , see Dealer (above)

Foodservice is a dealer that purchases and sells fresh and/or frozen fruits and vegetables in interstate or foreign commerce for distribution to restaurants, institutions, convenience stores, etc. These operations commonly also sell non-subject items as well.

Processor is a dealer that purchases fresh and/or frozen fruits and vegetables in interstate or foreign commerce for canning or processing or sells product in interstate or foreign commerce that has not had its kind or character changed (i.e., salad mixes, sliced fruit, vegetables, frozen or packed in ice or consists of cherries in brine, etc.). However, a processor is not subject if the purchasing and processing which changes the kind and character are both accomplished within the State where the produce is grown, even if the processed product is shipped out of the State.

Shipper is a dealer who operates at shipping point and is engaged in the business of purchasing produce from growers or others and distributing such produce in commerce by resale or other methods, or who handles such produce on joint account with others.

Trucker is a dealer that purchases and sells fresh and/or frozen fruits and vegetables in interstate or foreign commerce from its truck not as a retailer.

Retailer is a dealer when it purchases wholesale and jobbing quantities, but is only subject to a PACA license when the invoice cost of all purchases of produce (including frozen potato products such as French fries) exceeds $230,000 during a calendar year. In computing dollar volume, all purchases of fresh and frozen fruits and vegetables are to be counted, without regard to quantity involved in the transaction or whether the transaction was intrastate, interstate or foreign commerce.

Grocery Wholesaler is a dealer primarily engaged in the full-line wholesale distribution and resale of grocery and related nonfood items (such as perishable agricultural commodities, dry groceries, general merchandise, meat, poultry, and seafood, and health and beauty care items) to retailers. This term does not include persons primarily engaged in the wholesale distribution and resale of perishable agricultural commodities rather than other grocery and related nonfood items. Specifically, for an entity to be considered a grocery wholesaler, 50 percent or more of its annual gross sales must be

from the full-line distribution and resale of grocery and related nonfood items, and it cannot have more than 50 percent of its sales in perishable agricultural commodities. “Full-line” means that an entity must be supplying the retailer with a wide range of products such as the grocery and related nonfood items specified.

Broker means any person engaged in the business of negotiating sales and purchases of any perishable agricultural commodity in interstate or foreign commerce for or on behalf of the vendor or the purchaser, respectively. The 2000 pound quantity limitations do not apply to brokers. They are subject to PACA licensing with their first interstate or foreign commerce transaction. It is common in the industry to have fresh produce brokers and frozen produce brokers. Frozen produce brokers who negotiate contracts for frozen commodities exclusively for the vendor and the invoice value of the vendor's product does not exceed $230,000 in a calendar year are not subject; however, frozen produce brokers that are negotiating contracts for the buyer are subject no matter the invoice price.

Commission Merchant means any person engaged in the business of receiving in interstate or foreign commerce any perishable agricultural commodity for sale, on commission, or for or on behalf of another. For example, a person who receives a truckload of tomatoes; sells the product for a grower; charges a commission; and remits the net proceeds to the grower. The 2000 pound quantity limitations do not apply.

Grower is a business that grows its own fruits and vegetables and is not required to be licensed. However, a grower can be licensed on a voluntary basis and must comply with the PACA law while licensed.

Growers’ Agent means any person operating at shipping point who sells or distributes produce in commerce for or on behalf of growers or others and whose operation may include the planting, harvesting, grading, packing, and furnishing containers, supplies, or other services. The 2000 pound quantity limitations do not apply, because this type of business is considered a type of commission merchant.

FV-211 (06-13)

Individually owned or Sole Proprietorship means one person has complete ownership and is fully responsible for all activities.

Corporation is authorized by state law to act as a single entity and is registered with the secretary/ corporation commission of a state. The corporation can have elected officers and directors, an appointed registered agent and shareholders. Shareholders can be individuals, other corporations, LLC, partnerships, etc.

Limited Liability Company or “LLC” is a form of a legal entity where the state law provides for a firm to be treated as a partnership for tax purposes, while receiving the benefits from personal liability usually associated with a corporation. LLC’s are also registered with the secretary/ corporation commission of a state. NOTE: LLC’s are required to submit a copy of their

Articles of Organization and Written Operating Agreement with the application

Partnership is a voluntary contract between two or more persons who agree to carry on any business or venture together, upon the terms of mutual participation in its profits and losses,

this can be a verbal or written agreement. NOTE: Any change in partners will require a new license.

Limited Partnership is a partnership consisting of one or more general partners, jointly and severally responsible as ordinary partners, and by whom the business is conducted, and one or more special (limited) partners, contributing in cash payments a specific sum as capital, and who are not liable for the debts of the partnership beyond the funds contributed. Limited partnerships are required to be registered with the secretary/corporation commission of a state. NOTE: A change in any general partner will require a new license.

Limited Liability Partnership or “LLP” is a form of a legal entity where the state law provides for a firm to be treated as a partnership for tax purposes, while its individual partners receive protection against personal liability of certain partnership liabilities. LLP’s are also registered with the secretary/corporation commission of a state.

Association is commonly referred to as a Cooperative Marketing Association; a body of persons united and sometimes acting together without a charter in the pursuit of some common enterprise; basically a large partnership, but differs from a partnership in that it is not bound by the acts of individual partners, but only by those of its manager(s) or trustee(s). the NOTE: While PACA exempts growers from the licensing requirements, cooperative marketing associations must be licensed, even if the produce being handled is that solely of its members .

Trust is a right of property, real or personal, held by one party for the benefit of another; any arrangement whereby property is transferred with intention that it will be administered by a trustee for another’s benefit.

Estate is the property, real or personal, which a person has a right or interest and descends by law to heirs at that person’s death.

Note: The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 552a) and the Paperwork Reduction Act of 1995. The authority for requesting this information to be supplied on this form is the Perishable Agricultural Commodities Act, 1930, as amended, (7 U.S.C.

499a-499t) (499c, 499d). Furnishing the requested information is necessary for the administration of the Perishable Agricultural Commodities Act program.

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 0581-0031. The time required to complete this information collection is estimated to average 15 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. The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual's income is derived from any public assistance program (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

PENALTY:

Any person who operates without a valid and effective license shall be liable to a penalty of not more than $1,200 for each such offense and not more than $350 for each day it continues.

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