SC-216 915-Avocados Proxy Authorization

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

U.S. DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE SPECIALTY CROPS PROGRAM	PROXY AUTHORIZATION			Avocado Administrative Committee P.O. Box 900188 Homestead, FL 33090-0188 Tel: (305) 247-0848
NAME OF GROWER			EMAIL ADDRESS
MAILING ADDRESS (City, County, State, and Zip Code)
LOCATION OF EACH AVOCADO GROWER (either legal or from established landmarks)
NUMBER OF AVOCADO TREES OWNED
NUMBER OF 55 POUND UNITS OF AVOCADOS MARKETED TO DATE DURING THE CURRENT SEASON
NAME OF HANDLER OF THE FRUIT MARKETED
AUTHORIZATION, INCLUDING THE NAME AND ADDRESS OF THE PERSON WHO IS TO REPRESENT THE GROWER AT THE NOMINATION MEETING
NAME		ADDRESS (City, County, State, and Zip Code)
SIGNATURE		DATE
NOTE: Avocado Administrative Committee rules require that a person acting as proxy shall present proper authorization from each grower for whom he acts, to the election subcommittee not later than the January 20th immediately preceding the date of the election.

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 OMB 0581-0189. The time required to complete this information collection is estimated to average 10 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.

SC-216 (Exp. X/XXXX) Destroy previous editions.