MUS-NFC Mushroom Council Nomination Form

OMB No. 0581-0093

Nomination Form

To: Mushroom Council

Street

City, State Zip

My nomination(s) for candidate(s) in Region _____ are as follows:

1. ________________________	2. _________________________
________________________	_________________________
________________________	_________________________
________________________	_________________________
________________________	_________________________
3. ________________________	4. _________________________
________________________	_________________________
________________________	_________________________
________________________	_________________________
________________________	_________________________

From: I hereby certify that the company listed below produces over 500,000 pounds of mushrooms annually, on average, for fresh use.

Name: _________________________	Address: __________________________
Title: _________________________	__________________________
Company: _________________________	Phone: __________________________
Signature: _________________________	Date: __________________________

See reverse for Burden Statement.

Mushroom Council

Street, City, State Zip

(xxx) xxx-xxxx (xxx) xxx-xxxx fax

MUS-NFC (09/07)

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 30 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.

MUS-NFC (09/07)