No Form number Vidalia Onion Voter Registration Sheet

OMB No. 0581-0178

VIDALIA ONION COMMITTEE

P.O. Box 1609, Vidalia, GA 30475

Phone: (912) 537-1918 / Fax: (912) 537-2166

VOTER REGISTRATION SHEET

Marketing Order No. 955: Vidalia Onions Grown in Georgia

PART I. VOTER INFORMATION

A. Grower name: ____________________________________________________________________________

2. Address:________________________________________________________________________________

Telephone: ____________________ Fax: ___________________

2. Grower Organization (if any): ________________________________________________________________

_______________________________________________________________________________________

2. Please check in what capacity you are voting:

□ Sole Proprietorship (Individual Grower)

□ Partnership – Name of Partner: _____________________________________________________

Address: ____________________________________________________________

□ Corporation: ____________________________________________________________________

□ Other - (Please Specify): __________________________________________________________

2. Total Number of acres represented by this Ballot: _______________________________________________

PART II. VOTER CERTIFICATION

Making any false statements or representations in any matter within the jurisdiction of any agency of the United States, knowing it to be false, is a violation of title 18, section 1001, United States Code, which provides for penalty of fine, imprisonment, or both.

By my signature below, I certify that I am authorized to vote in my capacity as above-stated and that I will submit such evidence of such authority at the request of an Agent of the Secretary; that I produce Vidalia® Onions for market and that I have a proprietary interest therein in accordance with section 955.9 of the Marketing Order No. 955.

Further, I certify that the information provided above is accurate and correct to the best of my knowledge.

______________________________________________________ ____________________________

Signature Date

This information will be held in strict confidence.

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 0581-0178. 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.

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.

(Rev. 01/2017) Destroy previous editions.