HPR-BAL Ballot

OMB No. 0581-NEW

U.S. HONEY PRODUCER

RESEARCH, PROMOTION, AND CONSUMER INFORMATION ORDER

BALLOT

The nominees listed on this ballot are seeking a seat on the U.S. Honey Producer Board (Board). You are asked to cast your vote for (number) members, or write in the name of your choice for the above seat on the Board.

Choose (number) candidates only or provide name of write-in candidate.

REPRESENTATIVE CANDIDATES

[ ]

[ ]

[ ] Write-in Candidate:

Print Name: ______________________________________

PLEASE BE SURE TO COMPLETE THE FOLLOWING CERTIFICATION STATEMENT:

I certify that I have produced a minimum of 100,000 pounds of honey during the twelve-month period of Month XX, 20xx to Month XX, 20xx:

Signature: ____________________________________________________________

Print Name: ___________________________________________________________

Address: _____________________________________________________________

City: _______________________ State: ____________ Zip Code: ____________

Phone: ____________________________

Submission of Ballot to [Board/USDA]

Once you have completed and signed this ballot please place this ballot in the enclosed, self-addressed envelope and mail it to the [Board/USDA]. Incomplete ballots, unsigned ballots, or ballots received after Month xx, 20xx, will not be counted.

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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.

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-BAL (05-09)