Agricultural Marketing Service, Commodity Procurement Staff

1400 Independence Ave., SW, Room 3522-S, STOP 0239

Washington, DC 20250-0239

Voice 202.720.4517 Fax 202.720.5871

An Equal Opportunity Provider and Employer

ATTACHMENT A

Pilot Project for Procurement of Unprocessed Fruits and Vegetables

Application Form (August 2015)

Company Name: Date:

Contact: Phone:

Title: Email:

Address:

City: State: Zip:

Website (Optional):

Sales Point of Contact (who should States contact for orders or quotes):

Name, Title:

Phone: Email:

Identify the company’s business types. Check all that apply:

Distributor – Packs Product Distributor – Does Not Handle

Processor (cut, freeze, dry) Packing House

Grower Broker

Other (Explain):

Provide a list of domestic fruits and vegetables to be supplied (e.g., apples, apple slices, 

cabbage, carrots, chopped lettuce, oranges, salad mix, spinach, etc.):

By signing below, I agree to participate in the Pilot Project for the Procurement of Unprocessed 

Fruits and Vegetables, in accordance with the requirements listed and with the information 

provided in my application.

Signature of Company Representative responsible for the Pilot Project:

Signature: Date:
Agricultural Marketing Service

An Equal Opportunity Provider and Employer

ATTACHMENT B

Pilot Project for Procurement of Unprocessed Fruits and Vegetables

Self-Certification Form (December 2014)

Company Name: Date:

Contact: Phone:

Title: Email:

Address:

City: State: Zip:

Indicate if you have:

USDA Perishable Agricultural Commodities Act (PACA) License: ____YES ____NO

In general, any person who buys or sells more than 2,000 pounds of fresh or frozen fruits and 

vegetables in any given day is required to be licensed under the PACA. Wholesalers, processors, 

truckers, grocery wholesalers, and food service firms fit into this category.

Food Drug Administration (FDA) Food Facility Registration: ____YES ____NO

Bioterrorism Preparedness and Response Act of 2002 (Bioterrorism Act) (Pub. L. 107-188).

Section 415 of the FD&C Act (21 U.S.C. 350d) requires domestic and foreign facilities that 

manufacture, process, pack, or hold food for human or animal consumption in the U.S. to 

register with FDA.

Eligible vendors and their supplier(s)/subcontractor(s) must fully comply with all applicable

Federal, State, and Local laws and regulations, including, but not limited to labor, immigration, 

health and safety, and the environment.

Eligible vendors and their supplier(s)/subcontractor(s) must have available upon request a Food 

Safety Plan that a system which ensures the eligible vendor, as well as any of its suppliers 

throughout the supply chain, has implemented a verifiable food safety program.

All eligible vendors must carry product liability insurance to cover legal costs or other liabilities 

that could result from claim or lawsuits related to the supplied product. Proof of insurance must 

be supplied to USDA personnel upon request.

By signing below, the applicant certifies and attests to the above requirements for the Pilot

Project for the Procurement of Unprocessed Fruits and Vegetables.

Signature of Company Representative responsible for the Pilot Project:

Signature: Date:
Agricultural Marketing Service, Commodity Procurement Staff

1400 Independence Ave., SW, Room 3522-S, STOP 0239

Washington, DC 20250-0239

Voice 202.720.4517 Fax 202.720.5871

An Equal Opportunity Provider and Employer

ATTACHMENT C

Pilot Project for Procurement of Unprocessed Fruits and Vegetables 

Domestic Origin Certification Form (August 2015) 

Company Name: Date:

Contact: Phone: 

If imported product is brought into the facility during the production and shipment of product 

for this program, it is the company’s responsibility to have and to implement a segregation plan 

to ensure that only product of domestic origin is delivered. Vendor must maintain a copy of this 

form on file. 

Does your company process or handle fresh fruit and vegetable products originating from 

sources other than the United States, its territories or possessions, Puerto Rico, or the Trust 

Territories of the Pacific Islands? 

____YES ____NO If yes, attach a copy of your segregation plan explaining how such product 

is stored and processed separate from domestic product. It is the responsibility of the applicant 

to ensure supplier/subcontractor compliance that only domestic product is used in this program.

Do any of you Subcontractors/suppliers process or handle products originating from sources 

other than the United States, its territories or possessions, Puerto Rico, or the Trust Territories 

of the Pacific Islands? 

____YES ____NO 

A copy of supplier(s)/subcontractor(s) plan may be requested during an audit.

I certify that all products sold to the U. S. Department of Agriculture are of 100 percent 

domestic origin and that all above statements are true. I further certify that traceability 

documentation will be made available to USDA representative upon request.

WARNING: 18 U.S. C Part 1, chapter 47, Section 101 states that “ Except as otherwise 

provided in this section, whoever, in any manner within the jurisdiction of the executive, 

legislative, or judicial branch of the Government of the United States, knowingly and willfully 

(1) falsifies, conceals, or covers up by any trick, scheme, or devise of material fact; (2) makes 

any materially false, fictitious or fraudulent statement or representation; or (3) makes or uses 

any false writing or document knowing the same to contain materially false, fictitious, or 

fraudulent statement or entry; shall be fined under this title or imprisoned not more than 5 

years, or both.

Knowingly and willingly making false statements may also constitute a violation of the 

Perishable Agricultural Commodities Act (7 U. S. C., 499a-499t), and may also result in 

monetary penalties or license suspension or revocation.

Signature of Authorized Company Official or their Designee:

Signature: Date:
Agricultural Marketing Service, Commodity Procurement Staff

1400 Independence Ave., SW, Room 3522-S, STOP 0239

Washington, DC 20250-0239

Voice 202.720.4517 Fax 202.720.5871

An Equal Opportunity Provider and Employer

ATTACHMENT D

Pilot Project for Procurement of Unprocessed Fruits and Vegetables

List of Suppliers and Subcontractors Form (August 2015)

Company Name: Date:

Contact: Phone:

Provide a list of all suppliers and subcontractors, include product(s) supplied by each, food safety audit 

certification:

Supplier/Subcontractor Supplier/Subcontractor Role 

(distributor, processor, 

packinghouse, or grower)

Products Supplied Food Safety Audit 

Certification (Attach a 

Copy)

Signature of Authorized Company Official or their Designee:

Signature: Date: