OMB No. 0581-0178

(Exp. 3/31/2024) Destroy previous editions.

SOUTH TEXAS ONION COMMITTEE

901 Business Park Drive, Suite 500 Mission, TX 78572

Phone: (956) 584-9331 Fax: (956) 581-3912

APPLICATION FOR CERTIFICATE OF PRIVILEGE

FOR SPECIAL PURPOSE SHIPMENT REPORTS

Handler Certificate of Privilege No.:

Effective Date: Expiration Date:

Certificates of Privilege for Special Purpose Reports are required for the shipment of onions for other than fresh 

market purposes.

Purpose of Shipment: □ Canning or Freezing □ Relief or Charity □ Other ______________________

PERSON IN CHARGE OF SPECIAL PURPOSE FORMS: _____________________________________________

WHERE SHIPMENTS WILL ORIGINATE: ________________________________________________________

PLEASE LIST BELOW THE NAMES AND ADDRESSES OF CONSIGNEES YOU PLAN TO SEND SPECIAL 

PURPOSE ONIONS TO:

Name: __________________________________________ Name: _____________________________________

Name: __________________________________________ Name: _____________________________________

Name: __________________________________________ Name: _____________________________________

I, the undersigned applicant, understand and agree, that all onions granted a Certificate of Privilege for Special 

Purpose Shipments (Certificate), by virtue of this application and corresponding Special Purpose Shipment Reports, 

must be used for the purpose stated in this application and any deviation or infringement of this privilege which shall 

become known to me will be reported to the South Texas Onion Committee (Committee) promptly. Further, I will 

not knowingly sell or cause to be sold onions which have been granted a Certificate of Privilege and are to be used 

in violation of Certificate. I acknowledge that making of a false or fraudulent statement for the purpose of 

influencing the actions of a government agency shall, upon conviction, be subject to a fine or imprisonment, or both 

(18 U.S.C. 1001).

Company Name Authorized Signature

Mailing Address (Street or Box No., City, State, and Zip Code)

Physical Address (if different than above mailing address)

Telephone Number Fax Number Email Address

FOR OFFICE USE ONLY: COMMITTEE APPROVAL: DATE: 

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.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, 

offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national 

origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived 

from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by 

USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign 

Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the 

Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. 

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at 

http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the 

information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) 

mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; 

(2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender.