HPR-NOM Nomination for Appointment

OMB No. 0581-NEW

NOMINATION FOR APPOINTMENT TO THE U.S. HONEY Producer Research, Promotion, and Consumer Information Order

(7 CFR PART 1245)

The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 552a) and the Paperwork Reduction Act of 1995. The authority for requesting this information to be supplied on this form is the Commodity Promotion, Research, and Information Act of 1996, Pub. L. 104-127, 110 Stat. 1032 (7 U.S.C. 7411-7425). Furnishing the requested information is necessary for the administration of this program. Submission of the Tax Identification Number is mandatory, and will be used to determine affiliation or entity identification.

1. Please mark an “X” in the appropriate block for which you are submitting nominations. (Mark only one box.
If you are submitting nominations for more than one region below, a separate form must be filled out for each region.)

[ ] Region 1 [ ] Region 2 [ ] Region 3 [ ] Region 4 [ ] Region 5 [ ] Region 6 [ ] Region 7

2. Names and Addresses of Nominees.

3. Name of Person or Organization submitting these nominations

Name of Organization/Person: _______________________________________ Tax ID/Bus.#________________

Address: ___________________________________________________________________________________

City: _________________________ State: ________________ Zip: __________________

Phone No. ______________________ Fax No. _____________________

E-Mail: ________________________

Print Name and Title of Person Completing this Nomination

_____________________________________________________________________________________________________

Signature Date

Return Original Forms to: U.S. Honey Producer Board

Street, 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-NEW. 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.

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.

HPR-NOM (05-09)