F/H Form F(4) Hazelnut Ballot Handler (Position 1-3)

F/H FormF(4)
OMB CaNT. NO.
0581-0178

BOARD MEMBERSHIP BALLOT

The

hereby nominates
to be its member candidate and
to be its alternate member candidate.

Signature
Date

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 3 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 (l'DD). USDA is an equal
opportunity provider and employer.