FV-270 Nomination of Popcorn Processors to Serve on the Popcorn

REPRODUCE LOCALLY. Include form number and date on all reproductions.

Form Approved - OMB No. 0581-0093
Information is collected to obtain names of nominees for
appointment as members of the Board. Response is voluntary
(7 CFR 1215).

U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
FRUIT AND VEGETABLE PROGRAMS

NOMINATION OF POPCORN PROCESSORS TO SERVE
ON THE POPCORN BOARD

(Under the Popcorn Promotion, Research, and Consumer
Information Act and the Popcorn Promotion, Research, and
Consumer Information Order (7 CFR 1215).)

The Popcorn Promotion, Research, and Consumer Information Order provides that popcorn processors may nominate
eligible popcorn processors to serve on the Popcorn Board. Each popcorn processor may submit to the Popcorn Board
nomination(s) for each vacancy. Popcorn processors of more than 4 million pounds annually are eligible to nominate
and be appointed to the Popcorn Board. No more than one officer or employee of a processor may serve as a Board
member at the same time.
SECTION I - NOMINEE(S) (Type or print only.)
NAME

TITLE

COMPANY NAME

MAILING ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NUMBER (Include Area Code)

FAX NUMBER (Include Area Code)

NAME

TITLE

COMPANY NAME

MAILING ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NUMBER (Include Area Code)

FAX NUMBER (Include Area Code)

NAME

TITLE

COMPANY NAME

MAILING ADDRESS

CITY

STATE

TELEPHONE NUMBER (Include Area Code)

FAX NUMBER (Include Area Code)

FV-270 (06-07) Destroy previous editions.

ZIP CODE

(See reverse of form for Privacy Act Statement.)

SECTION II - PROCESSOR SUBMITTING THIS NOMINATION FORM (Type or print only.)
NAME

TITLE

MAILING ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NUMBER (Include Area Code)

FAX NUMBER (Include Area Code)

SECTION III - CERTIFICATIONSTATEMENT

I CERTIFY that during the period of January 1, 2005, through December 31, 2005, I processed
___________________ pounds of popcorn. (This information provided shall be treated as strictly
confidential.)
I further CERTIFY that the information contained in this certification section of this nomination form is true,
complete, and correct to the best of my knowledge and belief, and is made in good faith. If this nomination
form is being submitted on behalf of any group of individuals, partnership, corporation, or other business entity
engaged in the processing of popcorn, I also CERTIFY that I have the authority to submit this nomination form
and will submit evidence thereof if so requested by the Popcorn Board or the Department of Agriculture.
SIGNATURE

DATE

SECTION IV - MAILING ADDRESS

The Popcorn Board
ATTN: Genny Bertalmio
401 North Michigan Avenue
Chicago, Illinois 60611-4267

MAIL TO:

FAX No: (312) 321-5150
Telephone No: (312) 673-4883

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.
FV-270 (06-07)

REVERSE