OMB APPROVED - NO. 0581-0008 

CN-246 (09-03) (Previous editions are to be destroyed)

REPRODUCE LOCALLY. Include form number and edition date on all reproductions. 

APPLICATION FOR LICENSE

TO SAMPLE COTTON 

UNDER THE

UNITED STATES

COTTON STANDARDS ACT 

This application is authorized by law, 7 U.S.C. 51 et. seq. (U.S. Cotton Standards Act) and U.S.C. 473 c et. seq. (Smith-Doxey Act) and the regulations

issued thereunder (7 CFR Part 28). Furnishing the information is voluntary and no penalty will be imposed for failure to respond; however, this

information is necessary if we are to issue the license.

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 0581-0008. 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. 

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin,

gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (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, Room 326-W, Whitten Building, 1400 Independence Avenue, SW,

Washington, DC 20250-9410 or call 202-720-5964 (voice and TDD). USDA is an equal opportunity provider and employer. 

2. TYPE OF BUSINESS FOR WHICH 

 APPLICATION IS BEING MADE

 (Mark an "X" in appropriate block): 

INSTRUCTIONS: Answer all questions and send one completed application to the address shown at the bottom of the page. A company operating more than

one warehouse or gin may submit one application for all warehouses or gins. However, the name, location, and mailing address of each warehouse or gin to be

licensed should be listed on Page 2. A separate license will be issued for each warehouse or gin. 

 1. NAME IN WHICH BUSINESS IS CONDUCTED (Print or type): 

 3. LOCATION OF BUSINESS (Street and number, City State, and Zip Code): 

 4. MAILING ADDRESS (Street or P.O. Box Number, City, State, and ZIP Code): 5. NUMBER OF WAREHOUSES OR GINS 

 OPERATED: 

6. BUSINESS IS (Mark an "X" in appropriate block): 

OWNED BY ONE PERSON A PARTNERSHIP

7. IF THIS APPLICATION IS FOR A 

 WAREHOUSE, IS COTTON STORED 

 FOR THE PUBLIC (Mark an "X" in 

 appropriate block): 

CERTIFICATION STATEMENT: The undersigned, as a condition to the granting of the license, agrees to comply with

and abide by the terms of the United States Cotton Standards Act and Regulations. The statements made in the

foregoing application are hereby certified to be true to the best of the knowledge and belief of the undersigned. 

NOTE: Application must be signed by the owner or a responsible official of the warehouse or gin. 

A CORPORATION AN ASSOCIATION

SIGNATURE TITLE DATE

SUBMIT ELECTRONICALLY OR MAIL TO: FOR USE BY COTTON PROGRAMS ONLY

DATE LICENSE ISSUED

LICENSE NUMBER

YES NO

COTTON GIN

COTTON WAREHOUSE
REPRODUCE LOCALLY. Include form number and edition date on all reproductions. OMB APPROVED – No. 0581-0008 

APPLICATION FOR LICENSE TO SAMPLE COTTON 

UNDER THE UNITED STATES COTTON STANDARDS ACT 

INSTRUCTIONS: This page should be used to provide additional names, locations and 

mailing addresses of warehouses or gins to be licensed. 

NAME IN WHICH BUSINESS IS CONDUCTED NAME OF OWNER OR RESPONSIBLE OFFICIAL 

NAME, LOCATION, AND MAILING ADDRESS (If Different) OF ADDITIONAL WAREHOUSES OR GINS (Street or P.O. 

Box Number, City, State, and Zip Code)

NAME IN WHICH BUSINESS IS CONDUCTED NAME OF OWNER OR RESPONSIBLE OFFICIAL 

NAME, LOCATION, AND MAILING ADDRESS (If Different) OF ADDITIONAL WAREHOUSES OR GINS (Street or P.O. 

Box Number, City, State, and Zip Code)

NAME IN WHICH BUSINESS IS CONDUCTED NAME OF OWNER OR RESPONSIBLE OFFICIAL 

NAME, LOCATION, AND MAILING ADDRESS (If Different) OF ADDITIONAL WAREHOUSES OR GINS (Street or P.O. 

Box Number, City, State, and Zip Code)

CN-246 (09-03 ) (Previous editions are to be destroyed) Page 2