FV-326 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.

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-326 (Rev. 02/17) Destroy previous editions.