No Form number Vidalia Onions Voter Registration Sheet

VIDALIA ONION COMMITTEE
VOTER REGISTRATION SHEET

Part I.

VOTER INFORMATION

A.

Grower'sname:

B.

Complete MailingAddress:

Phone Number (Area Code):

c.

GrowerOrganization(Ifany):

D.

Please checkinwhatcapacityyouare voting:

D
D

Sole Proprietorship(Individual
Grower)
Partnership- NameofPartner:
Address:

E.

D

Corporation:

D

Other

- (Please

Specify):

Total Number of acres represented bythis 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
of $1 0,000.00 or imprisonment of not more than 5 years or both.
By my signature below, I certify that I am authorized to vote in my capacity as above-stated and that I willsubmit
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 Federal Marketing Order.
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.
(Over)

Note: The following statements are made in accordance with the Privacy Act 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, Sees. 1-19,48 Stat. 31, as amended, (7 U.S.C. 601-674).
Furnishing the requested information is necessary for the administration of the marketing order program.
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 maintainingthe data needed, and completing and
reviewing the collection of information.
The U.S. Department of Agriculture (USDA) prohibits discriminationin all its programs and activities on the
basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familialstatus,
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 disabilitieswho require alternative means for communication of program information
(Braille, large print, audiotape, etc.) should contact USDA's TARGET Center at (202) 720-2600 (voice and
TDD). To file a complaint of discrimination,write to USDA, Director, Office of Civil Rights, 1400
Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382
(TDD). USDA is an equal opportunity provider and employer.