Form Ams-15 - Organic Exemption Request Form - 2007 printable pdf download

OMB No. 0581-0093

Organic Exemption Request Form

Persons that produce and market only products eligible to be labeled as “100 percent organic” may request exemption from

assessment under research and promotion programs. The information on this form is required to make a determination

concerning a person’s eligibility for exemption.

Type of Operation:

Producer

Importer



Please complete the following:

Company name:

Phone:

Street address:

Fax:

E-mail (optional):

City/State/Zip code:

In order to be exempt, the above-named company must meet all of the following

(please check)

Operates under an approved organic system plan authorized by the National Organic Program



(NOP) (7 CFR Part 205)

Produces or imports only products eligible for a 100% organic label under the NOP



Is not a split operation as defined by the Organic Foods Production Act of 1990

Please list all commodities produced or imported

(use continuation sheet if necessary):

Eligible to be labeled as

Commodity

100% Organic?

Commodity

100% Organic?

__________________________



__________________________



__________________________



__________________________



__________________________



__________________________



A copy of this company’s organic farm or organic handling operation certificate provided by



a USDA-accredited certifying agent must be attached. Importers should attach a copy of

each person

this certificate from

from whom they receive products.

Certification Statement

I certify that, at the signing of this statement and for the signed date, the above is true.

____________________________

_____________________________

_____________

Signature

Title

Date

Hass Avocado Board

Please return this form to:

25212 Marguerite Pkwy. Ste. 250

Mission Viejo, CA 92692

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 0581-0093. The time required to complete this information collection is

estimated to average 30 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 USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410, or

call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

AMS-15 (08-07)