Form Approved By Omb No - Agricultural Marketing Service - Usda Page 2

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FORM APPROVED BY OMB No. 0581-0125

3. It is mutually agreed that with respect to:

a. Length of Service - That the audit results for GAP&GHP audits are valid for one year from the date of the initial audit,

provided that the USDA acceptance criteria is met on both the initial audit and any unannounced audits that may be

required by the program. For all other audit programs, the length of service is outlined in the specific audit program

policy guide. This agreement shall remain in effect for the length of time the auditee remains a participant in the

specific audit program.

b. Maintaining Certification - That a company’s information will only remain on the USDA website if any and all

unannounced audits show satisfactory adherence to the program. If the minimum passing score is not achieved, the

company’s information will be removed from the website until a follow-up audit is conducted by AMS verifying that

effective corrective actions have been taken and the company attains the minimum score on all appropriate scopes of

the audit.

Approved By:

Name of Applicant (Print):

Title:

Signature:

Date:

USDA Agricultural Marketing Service, Fruit & Vegetable Program/ Federal or Federal-State Inspection Program

Supervisor

Name of Representative (Print):

Title:

Signature:

Date:

(OPTIONAL) The applicant request AMS to release audit results to:

a. Web-based Systems- The auditee designates the audit report is loaded into the following database (check all that

apply):

___ icix

___ Azzule Systems

___ FoodLogiQ

b. Other Parties- The auditee designates the specific applicant checklist and results of individual questions be sent to:

___________________________________

_____________________________

___________________

(Name of Company/Representative)

(Email Address)

(Phone)

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 0581-0125. The time required to complete this information collection is estimated to

average 2 minutes/hours 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.

FV-651 (04-14) (Previous editions are to be destroyed)

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