FV-236 Hass Avocado Registration & Official Referendum Ballot

OMB No. 0581-0093

HASS AVOCADO PROMOTION, RESEARCH, AND INFORMATION ORDER

(7 CFR 1219)

Registration Form

for the

Hass Avocado Promotion, Research, and Information Order

Referendum on __________

Name:__________________________ Title (if any):________________

Business address:______________________________________________________

Street

__________________________________ ______________

City and State Zip Code

Business phone number:_________________________________________________

______I produced Hass avocados from January 1, 20XX to December 31, 20XX

______I imported Hass avocados from January 1, 20XX to December 31, 20XX

I certify that I am eligible to register to vote in the referendum.

Signature:________________________________ Date:_________________

Fax to:XXX-XXX-XXXX Mail to: AMS-USDA Referendum

Hass Avocado Registration

Street Address/P.O. Box

City, State Zip Code

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 0581-0093. The time required to complete this information collection is estimated to average 15 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.

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 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.

FV-326 (08/07)

OMB No. 0581-0093

United States Department of Agriculture

Agricultural Marketing Service

OFFICIAL REFERENDUM BALLOT

Hass Avocado Promotion, Research, and Information Order

To be counted, completed ballots must be received by USDA on or after Month xx, 20xx and before xx:xx p.m. Eastern Standard Time on Month xx, 20xx.

NOTE: Only one vote will be counted for each eligible producer and importer of fresh Hass avocados. Incomplete and unsigned ballots will be INVALID and will not be counted in the referendum.

1. CERTIFICATION (Check one)

______I am currently a fresh Hass avocado PRODUCER.

______I am currently an IMPORTER of fresh Hass avocados

2. VOTE (Mark one box)

Do you favor the continuance of the Hass Avocado Promotion, Research,
and Information Program?

Yes  No 

III. SIGNATURE

ALL BALLOTS MUST BE SIGNED AND DATED BELOW IN ORDER TO BE COUNTED.

I CERTIFY that I am the person authorized to cast this ballot and that the information contained on this ballot is true, complete, and correct to the best of my knowledge and belief, and is made in good faith. If this ballot is being cast on behalf of any group of individuals, partnership, corporation, or other business entity engaged in the product or importation of Hass avocados, I also CERTIFY that I have the authority to cast this ballot.

X _____________________________ _______________
SIGNATURE DATE

_______________________________________ __________________________

COMPANY NAME BUSINESS TELEPHONE NUMBER

IV. MAILING

Return ballot in the enclosed, postage-paid envelope.

FALSIFICATION OF INFORMATION OR MISREPRESENTATION OF IDENTITY ON THIS GOVERNMENT DOCUMENT MAY RESULT IN A FINE OF NOT MORE THAN $10,000 OR IMPRISONMENT FOR NOT MORE THAN FIVE YEARS OR BOTH. (18 U.S.C.1001)