SC-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 SPECIALTY CROPS PROGRAM		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 of the U.S. Code, which provides for a penalty or a fine or imprisonment, or both.
1. NAME**			TEL. NO. (include area code)
MAILING ADDRESS (City, County, State, and Zip Code)			EMAIL ADDRESS
2. NAME**			TEL. NO. (include area code)
MAILING ADDRESS (City, County, State, and Zip Code)			EMAIL ADDRESS
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.

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 OMB 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.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. USDA is an equal opportunity provider, employer, and lender.

SC-208 (Rev. 9/2016. Destroy previous editions.)