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SC-212 (Exp. 01/31/2027. Destroy previous editions.)

REPRODUCE LOCALLY. Include form number and date on all reproductions. OMB No. 0581-0189

REPORT OF SPECIAL Avocado Administrative Committee

U.S. DEPARTMENT OF AGRICULTURE PURPOSE SHIPMENT P.O. Box 900188 AGRICULTURAL MARKETING SERVICE Homestead, FL 33090-0188 SPECIALTY CROPS PROGRAM UNDER CERTIFICATE OF

PRIVILEGE Tel: (305) 247-0848

SHIPPED TO

ADDRESS (City, County, State, and Zip Code)

NAME OF CARRIER TRUCK LICENSE NUMBER

PURPOSE: □ Seed □ Charity (fresh) □ Processing

NUMBERS OF CONTAINERS CONTAINER NUMBER OF CONTAINERS CONTAINER

SHIPPED WEIGHT RECEIVED WEIGHT

DATE SHIPPED LOADING POINT DATE RECEIVED UNLOADING POINT

CERTIFICATION STATEMENT: The undersigned If used other than stated by Shipper, specify:

certifies to the Committee and the Secretary of

Agriculture that these avocados are being shipped in

accordance with current Marketing Order Regulations

for use only for the purpose stated. I realize that the CERTIFICATION STATEMENT: The undersigned

making of a false statement, knowing it to be false, is a acknowledges receipt of and certifies to the Committee

violation of Title 19, Section 1001, of the United States and the Secretary of Agriculture that the above avocados

Code, among other statues, which provides for fine and will be used for the purpose indicated. I realize that the

imprisonment. making of a false statement, knowing it to be false, is a

NAME OF SHIPPER violation of Title 19, Section 1001, of the United States

Code, among other statues, which provides for fine and

REGISTERED HANDLER NUMBER (if applicable) imprisonment.

PACA LICENSE NUMBER (if applicable) NAME OF RECEIVER

ADDRESS (City, County, State, and Zip Code) ADDRESS (City, County, State, and Zip Code)

SIGNATURE OF SHIPPER SIGNATURE OF RECIEVER

SHIPPER INSTRUCTIONS: Fill out this report for each RECEIVER INSTRUCTIONS: Upon receipt of these

Special Purpose Shipment. Sign all four (4) copies. Mail the forms, promptly complete the pink copy and mail to the

original (white) copy to the Committee. Forward the yellow Committee. Retain the yellow copy for your files. FAILURE

and pink copies to the receiver. Retain the gold copy for your TO COMPLY WILL RESULT IN CANCELLATION OF

files. FAILURE TO COMPLY CONSTITUTES A CERTIFICATES PERMITTING SHIPMENTS OF

VIOLATION OF MARKETING ORDER NO. 915. SPECIAL PURPOSE AVOCADOS TO YOUR FIRM.