Form C-6 Declaration of Hawaii-Grown Coffee Geographic Region Statement - Hawaii

Form C-6 is a Hawaii Department of Agriculture form also known as the "Declaration Of Hawaii-grown Coffee Geographic Region Statement". The latest edition of the form was released in July 1, 2014 and is available for digital filing.

Download an up-to-date Form C-6 in PDF-format down below or look it up on the Hawaii Department of Agriculture Forms website.

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Form C-6 (7/14)
DECLARATION OF HAWAII-GROWN COFFEE
GEOGRAPHIC REGION STATEMENT
I understand that the Hawaii Department of Agriculture and Hawaii law enforcement agencies of the State and counties will use the
following information and representation regarding the geographic region of coffee beans. I further understand that any misstatements I
provide herein may constitute a violation of sections contained in Chapters 708, 147, and 145 of the Hawaii Revised Statutes (HRS) and
may result in the penalties set forth in Chapters 708, 147, and 145 HRS.
I certify that the following lot(s) of coffee beans were produced in the geographic region of ______________________ as defined in
Section 4-143-3, Hawaii Administrative Rules (HAR) on the island of _______________, tax map key nos.
_______________________________________________________________________________________.
No. of
No. of
Sacks
Sacks
Grade
or
Grade
or
(if applicable)
Packages
Net Weight (lbs.)
(if applicable)
Packages
Net Weight (lbs.)
Producer/Distributor
Receiver
(input above line)
(input above line)
Print Name of Company
Print Name of Company
Address
Address
City, State, Zip Code
City, State, Zip Code
Phone No.
Phone No.
Print Name of Contact Person
Print Name of Contact Person
TRANSPORTER (IF APPLICABLE)
: _______________________________
.:___________________________________
COMPANY NAME
PHONE NO
ADDRESS: ______________________________________________
SIGNATURE:______________________________________________
____________________________
CITY/STATE/ZIP CODE
PRINT NAME:_____________________________________________
IF YOU HAVE ANY QUESTIONS, PLEASE CALL
Hawaii Department of Agriculture, Commodities Branch
Honolulu: 832-0700
Capt. Cook, Kona: 323-7590
Hilo: 974-6514
Maui: 873-3554
Kauai: 271-7133
Distribution: One copy for seller
May be applied to each coffee container in shipment
One copy for buyer
One copy for transporter
Retain document for six years
Form C-6 (7/14)
DECLARATION OF HAWAII-GROWN COFFEE
GEOGRAPHIC REGION STATEMENT
I understand that the Hawaii Department of Agriculture and Hawaii law enforcement agencies of the State and counties will use the
following information and representation regarding the geographic region of coffee beans. I further understand that any misstatements I
provide herein may constitute a violation of sections contained in Chapters 708, 147, and 145 of the Hawaii Revised Statutes (HRS) and
may result in the penalties set forth in Chapters 708, 147, and 145 HRS.
I certify that the following lot(s) of coffee beans were produced in the geographic region of ______________________ as defined in
Section 4-143-3, Hawaii Administrative Rules (HAR) on the island of _______________, tax map key nos.
_______________________________________________________________________________________.
No. of
No. of
Sacks
Sacks
Grade
or
Grade
or
(if applicable)
Packages
Net Weight (lbs.)
(if applicable)
Packages
Net Weight (lbs.)
Producer/Distributor
Receiver
(input above line)
(input above line)
Print Name of Company
Print Name of Company
Address
Address
City, State, Zip Code
City, State, Zip Code
Phone No.
Phone No.
Print Name of Contact Person
Print Name of Contact Person
TRANSPORTER (IF APPLICABLE)
: _______________________________
.:___________________________________
COMPANY NAME
PHONE NO
ADDRESS: ______________________________________________
SIGNATURE:______________________________________________
____________________________
CITY/STATE/ZIP CODE
PRINT NAME:_____________________________________________
IF YOU HAVE ANY QUESTIONS, PLEASE CALL
Hawaii Department of Agriculture, Commodities Branch
Honolulu: 832-0700
Capt. Cook, Kona: 323-7590
Hilo: 974-6514
Maui: 873-3554
Kauai: 271-7133
Distribution: One copy for seller
May be applied to each coffee container in shipment
One copy for buyer
One copy for transporter
Retain document for six years

Download Form C-6 Declaration of Hawaii-Grown Coffee Geographic Region Statement - Hawaii

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