No Form number Vidalia Onion Voter Registration Sheet

OMB No. 0581-0178

VIDALIA ONION COMMITTEE

P.O. Box 1609, Vidalia, GA 30475

Phone: (912) 537-1918 / Fax: (912) 537-2166

VOTER REGISTRATION SHEET

Marketing Order No. 955: Vidalia Onions Grown in Georgia

PART I. VOTER INFORMATION

A. Grower name: ____________________________________________________________________________

2. Address:________________________________________________________________________________

Telephone: ____________________ Fax: ___________________

2. Grower Organization (if any): ________________________________________________________________

_______________________________________________________________________________________

2. Please check in what capacity you are voting:

□ Sole Proprietorship (Individual Grower)

□ Partnership – Name of Partner: _____________________________________________________

Address: ____________________________________________________________

□ Corporation: ____________________________________________________________________

□ Other - (Please Specify): __________________________________________________________

2. Total Number of acres represented by this 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, imprisonment, or both.

By my signature below, I certify that I am authorized to vote in my capacity as above-stated and that I will submit 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 Marketing Order No. 955.

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.

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 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.

Rev. 01/2014. Destroy previous editions.