FV-208 915-Avocados Committee Grower Registration

FORM APPROVED - OMS NO. 0581-0189

REPRODUCELOCALLY. Include form number and date on all reproductions.
U.S. DEPARTMENT

OF AGRICULTURE

AGRICULTURAL
MARKETING
SERVICE
FRUIT AND VEGETABLE
PROGRAMS

DATE

GROWER REGISTRATION

Florida Avocado Administrative Committee
18710 S.W. 288th Street, P.O. Box 900188
Homestead, FL 33090-0188
TELEPHONE: (305) 247-0848

DISTRICT*

The making of any false statements or representations in any matter within the jurisdiction of any agency of the United States, knowing it to be false, is in
violation of Title 18, Section 1001, U.S. Code, which provides for a penalty or a fine of not more than $10,000 or imprisonment of not mote than five years
or both.
TELEPHONE NUMBER (Include area code)

**1. NAME
MAILING ADDRESS (City, County, State, and ZIP,

TELEPHONE NUMBER (Include area code)

**2. NAME
MAILING ADDRESS (City, County, State, and ZIp,

LOCATION OF GROVE (Legal)

CERTIFICATION STATEMENT: I hereby certify that I have proprietary interest in a commercial avocado grove containing not less than ten (10)
bearing avocado ttees and that I am authorized to act at election meetings for any and all other persons with interest in such grove.
1. SIGNATURE

DATE

2. SIGNATURE

DATE

REGISTRATION NUMBER

*District:

**Name:

1 means Dade County
2 means all counties south of the Production area boundaries except Dade County.
Each legal entity will need to make available legal documents that substantiate that it is a corporation, partnership, lessee,
The following statements are made in accordance with the PrivacyAct of 1974(5 U.S.C. 552a) and the Paperwork Reduction Act of 1995. The authority for
requesting this information to be supplied on this form is the Agricultural Marketing Agreement Act of 1937, secs. 1-19,48 Stat. 31, as amended,
601-674). Furnishing the requested information is necessary for the administration of the marketing order program.

(7 U.S.C.

According to the Paperwork Reduction Act of 1995.an agency may n~naucr
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'6~B control number for this information collection is 0581-0189. The time required
to complete this information collection is estimated to averag~ I;unutes 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.

NOTE:

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age,
disability, and where applicable, sex, marital status, familial status, parental status. religion, sexual orientation, genetic information. political beliefs,
reprisal, or because all or part of an individual's income is derived from any public assistance program (Not all prohibited bases apply to all programs.)
Persons with disabilities who require alternative means for communication of program information (Braille,large print, audiotape, etc.) should contact
USDA's TARGETCenter at (202)720-2600(voice and TOO).
To file a complaint of discrimination, write to USDA, Director. Office of Civil Rights. !4DO Independence
call (800) 795-3272 (voice) or (202) 720-6382 (TOO). USDA is an equal opportunity

FV-208 (05-07)

Destrov previous editions.

provider and employer.

Avenue,

S.W., WashIngton,

D.C. 2025l1-9410, or