FV-208 915-Avocados Committee Grower Registration

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

U.S. DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE FRUIT AND VEGETABLE PROGRAMS		GROWER REGISTRATION		Avocado Administrative Committee P.O Box 900188 Homestead, FL 33090-0848 Tel: (305) 247-0848
DATE	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 a violation of Title 18, Section 1001 or the U.S. Code, which provides for a penalty or a fine of not more than $10,000, or imprisonment of not more than five years, or both.
1. NAME**			TEL. NO. (include area code)
MAILING ADDRESS (City, County, State, and Zip Code)
2. NAME**			TEL. NO. (include area code)
MAILING ADDRESS (City, County, State, and Zip Code)
LOCATION OF GROVE (Legal)
CERTIFICATION STATEMENT: I hereby certify that I have a proprietary interest in a commercial avocado grove containing not less than ten (10) fruit-bearing avocado trees, and that I am authorized to act at election meetings for any and all other persons with interest in such grove.
SIGNATURE				DATE
SIGNATURE				DATE
REGISTRATION NUMBER:
*District: 1 means Dade County; 2 means all counties south of the Production area boundaries except Dade. **Name: Each legal entity will need to make available legal documents that substantiate that it is a corporation, partnership, or lessee.

NOTE: 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 0581-0189. 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.

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 USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

FV-208 (Rev. 7/10. Destroy previous editions.)