OMB No. 0581-0125 

Exp. 10/31/2026

APPLICATION FOR LICENSE TO SAMPLE OR INSPECT FRUITS, VEGETABLES, 

NUTS AND MISCELLANEOUS PRODUCTS 

In accordance with the Regulations Governing Inspection and Certification of Fruits and Vegetables and Related Products (7 CFR 51 and 52), I hereby apply for a license to sample 

and/or inspect products and to certify with respect to the identification, location, kind, grade, condition, or condition of the containers in the lots of such products for applicants 

desiring inspection service under the cited regulations. 

NAME (LAST, FIRST, M.I.): 

ADDRESS: E-MAIL ADDRESS: 

EDUCATION 

HIGH SCHOOL: CITY, STATE: 

DATES: DID YOU GRADUATE? DEGREE: 

COLLEGE: CITY, STATE: 

DATES: DID YOU GRADUATE? DEGREE: 

COLLEGE: CITY, STATE: 

DATES: DID YOU GRADUATE? DEGREE: 

EMPLOYERS: PRESENT AND PREVIOUS 3 YEARS 

INCLUSIVE DATES NAME AND ADDRESS OF EMPLOYER OCCUPATION OR DUTIES 

FROM: 

TO: PRESENT 

FROM: 

TO: 

FROM: 

TO: 

CERTIFICATION 

This is to certify that I agree, as a condition to the granting of the license applied for, to faithfully comply with all terms and conditions of the Regulations cited above with respect to 

the duties of a licensee of the U.S. Department of Agriculture (USDA). As a licensee of the USDA, I agree to the following: 

• I will not sample or inspect any lot of products to which I or my employer is an interested party.

• To abide by all Federal instructions governing the sampling and inspection of fruits, vegetables, nuts and miscellaneous products, whether given to me in the form of 

handbooks, memorandums, written instructions, or personally by the Federal Supervising Inspector to whom I am responsible. 

• In making inspections based on Federal grades, to accept the interpretation of such grades given to me by the Federal Supervising Inspector or other authorized 

representatives of the USDA, Agricultural Marketing Service. 

• To make clear and accurate inspection notes, including scoring of grade, defects and other memorandums, of each inspection made by me as shall be directed by the Federal 

Supervising Inspector.

• To prepare my certificates from such notes strictly in accord with Federal instructions. 

• To surrender my license card when so requested by the Federal Supervising Inspector or upon expiration (December 31 next following date of issue), either to him/her or by 

mail to the Specialty Crops Inspection Division, Agricultural Marketing Service, U.S. Department of Agriculture, 1400 Independence Ave. SW, Washington, DC 20250. 

The statements made by me in this application are true, complete, and correct to the best of my knowledge and belief. 

APPLICATION FILED IN THE STATE OF: SIGNATURE OF LICENSEE: 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 is 0581-0125. The time required to complete this information collection is estimated to average 2 

minutes per response, including the time for reviewing the instruction, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the 

collection of information. 

SC-468 (1-2024) Destroy previous editions. USDA is an equal opportunity provider, employer, and lender.
 

 

 

 

 

Non-Discrimination Policy: 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. 

SC-468 (1-2024) Destroy previous editions. USDA is an equal opportunity provider, employer, and lender.