_______________________________________________________________________________________ 

______________________________________________________ ____________________________ 

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: ____________________________________________________________________________ 

B. Address:________________________________________________________________________________ 

Telephone: ____________________ Fax: ___________________ 

C. Grower Organization (if any): ________________________________________________________________ 

D. Please check in what capacity you are voting: 

□ Sole Proprietorship (Individual Grower) 

□ Partnership – Name of Partner: _____________________________________________________ 

Address: ____________________________________________________________ 

□ Corporation: ____________________________________________________________________ 

□ Other - (Please Specify): __________________________________________________________ 

E. 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. 

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: program.intake@usda.gov. USDA is an equal opportunity provider, employer, and lender. 

(Exp. 3/31/2024) Destroy previous editions.