Form Fgis-944 - Application For License Under The United States Grain Standards Act (Usgsa) And/or The Agriculture Marketing Act (Ama) Of 1946

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This is a fillable form; fill out, print, sign original, and mail to service area GIPSA Field Office.
U.S DEPARTMENT OF AGRICULTURE
FORM APPROVED: OMB No. 0580-0013
FEDERAL GRAIN INSPECTION SERVICE
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a
APPLICATION FOR LICENSE UNDER THE
person is not required to respond to a collection of information unless it displays a valid OMB control
UNITED STATES GRAIN STANDARDS ACT (USGSA)
number. The valid OMB control number for this information collection is 0580-0013. The time required
to complete this information collection is estimated to average 8 minutes per response, including the time
AND/OR
for reviewing instructions, searching existing data sources, gathering and maintaining the data
THE AGRICULTURE MARKETING ACT (AMA) OF
needed, and completing and reviewing the collection of information.
1946
INSTRUCTIONS: This application must be completed in English, be typewritten or printed in ink and forwarded to the local FGIS office.
2.
1.
APPLICANT'S NAME
BIRTHDATE (mm/dd/yyyy)
3.
APPLICANT'S COMPLETE HOME MAILING ADDRESS (Including
4.
NAME OF EMPLOYING AGENCY
5.
SERVICE POINT WHERE APPLICANT WILL BE
Zip Code)
STATIONED
7.
TYPE OF LICENSE FOR WHICH YOU
8.
HAVE YOU EVER BEEN LICENSED BY FGIS TO
6.
SUPERVISING FIELD OFFICE
ARE APPLYING
PERFORM USGSA/AMA FUNCTIONS?
USGSA
AMA
Yes
No
9.
LICENSE FOR WHICH YOU ARE APPLYING:
WAREHOUSEMAN SAMPLER
SAMPLER
CONTRACT SAMPLER - (AMA)
TECHNICIAN
WEIGHER
INSPECTOR
10.
CONFLICT OF INTEREST QUESTIONAIRE
USGSA License
Do you, your spouse, your minor children, or any blood relative immediately residing in your household, serve as an officer director, committee member, or employee of any
business entity owning or operating any grain elevator or warehouse, or engage in the merchandising, storage, commercial transportation, or other commercial handling
of grain? Yes
No
Do you, your spouse, your minor children, or any blood relative immediately residing in your household, have stock or other financial interest, directly, or indirectly, in any grain
elevator or warehouse, or any other business entity involved in the merchandising, storage, commercial transportation, or other commercial handling of grain? Yes
No
Do you know of any other matters, family relationships, or other personal relationships, which might give rise to an apparent or possible conflict of interest involving your present
employment and any business entity described above? Yes
No
AMA License
Are you, your spouse, or relatives residing in your household employed by, or receiving a financial consideration from a company that merchandises, handles, stores, or processes
agricultural commodities that you would be licensed to sample or inspect? Yes
No
Do you, your spouse, or relatives residing in your household have a financial interest in a company that merchandises, handles, stores, or processes agricultural commodities that you
would be licensed to sample or inspect? Yes
No
Do you, your spouse, or relatives residing in your household have a financial interest in any of the raw materials or companies providing the raw materials from which the
commodities that you would be licensed to sample or inspect are manufactured? Yes
No
Certification: Knowing that false or fraudulent statements to an Agency of the United States Government are subject to penalty (a fine of not more than $10,000 or imprisonment for
not more than 5 years, or both), (18 U.S.C. 1001). I declare that the foregoing statements are true to the best of my knowledge and belief. Further, as a condition to the granting of
this license, I agree to comply and abide by the terms of the USGSA, regulations and the AMA, regulations, thereunder and instructions prescribed by FGIS. I further understand
that the license issued to me will terminate 3 years from the date of issuance, unless renewed and that upon resignation or dismissal, my license will be suspended for 1 year
or its termination date.
11.
SIGNATURE OF APPLICANT
12.
DATE (mm/dd/yyyy)
13.
NAME and/or SIGNATURE AGENCY MANAGER
14. TI
TLE
15. DA
TE (mm/dd/yyyy)
USDA USE ONLY
17. NAME and/or SIGNATURE (FIELD OFFICE)
18. DATE (mm/dd/yyyy)
16.Action
APPROVED
DISMISSED
The following declaration is made pursuant to Public Law 93-579 (Privacy Act of 1974), solicitation of personal information. FGIS program Systems of Records includes
History Records for Licensed Nonfederal Employees. Statutory authority to collect personal information is contained in 7 U.S.C. et seq. Pursuant to Executive Order 9397 of
November 22, 1943, disclosure of your social security number is necessary to provide requested information. The principal purpose for the collection of this data is the
enforcement of the United Grain Standards Act and the Agriculture Marketing Act of 1943. The routine use of this information is to evaluate acceptability of applicant and to
evaluate/resolve possible conflicts of interest. The information may be referred to states or other federal agencies for purposes relating to verification of employment or
required records or reports. Information also may be referred to the Department of Justice or to other investigative and law enforcement agencies for investigation, prosecution
and/or administrative action resulting from violation of law, rule, regulation, instruction, or order, or to a Congressional Office in response to a constituent's request for release
of his/her record.
FORM FGIS-944 (06-07) previous editions are obsolete. This form also replaces Form FGIS-943, which is obsolete. Expires January 2018
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