LS-25 Application for Certification of Organization or Associa

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

FORM APPROVED. - OMB NO. 0581-0093

U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

APPLICATION FOR CERTIFICATION OF ORGANIZATION OR ASSOCIATION
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.

Organizations or associations must apply for certification by the Secretary to be eligible to participate in the making of
nominations of cattle producers to serve as members of the Cattlemen's Beef Promotion and Research Board as provided in
the Beef Promotion and Research Act of 1985. Information submitted in response to all items must be complete. Please
type or print clearly. Send form to:
Marketing Programs Branch
Livestock and Seed Program, AMS
U.S. Department of Agriculture, Room 2628-S
1400 Independence Avenue, SW, MAIL STOP 0251
Washington, DC 20250-0251
FAX: 202/720-1125
1. NAME AND ADDRESS OF ORGANIZATION (Street address or P.O. Box No., City, State, ZIP)

2. TYPE OF ORGANIZATION
(Please check one)

□
□
□
TELEPHONE NO. AND AREA CODE
3. STATE

FACSIMILE NO. AND AREA CODE

4. TOTAL PAID MEMBERSHIP
(Most RECENT FULL calendar year)
IN 20________

STATE CATTLE ASSOCIATION
STATE GENERAL FARM
OTHER

5. NUMBER OF PAID MEMBERS ENGAGED
IN CATTLE PRODUCTION
(Most RECENT FULL calendar year)

NO.________

IN 20________

NO.________

6. TOTAL ESTIMATED INVENTORY OF
CATTLE OWNED BY PAID MEMBERS
(Most RECENT FULL calendar year)
AS OF JAN. 1, 20________

NO.________

7. AS EVIDENCE OF THE STABILITY AND PERMANENCY OF THE ORGANIZATION, GIVE:
A. No. of years in existence
B. No. of paid members during each of the last four calendar years:
20________

20________

20________

20________

C. Other Evidence (Explain)

I hereby certify that: (1) a primary or overriding purpose of this organization or association is to promote the economic welfare of cattle
producers, and (2) the information provided in response to the above items is true, complete, and correct to the best of my knowledge. The
Secretary of Agriculture may examine our books, documents, papers, records, files, and facilities to verify any of the information
submitted and may procure such other information as may be required to determine this organization's or association's eligibility for
certification.
8. NAME AND TITLE OF PERSON COMPLETING THE APPLICATION
(Type or print)

10. SIGNATURE

9. E-MAIL ADDRESS ([email protected])

11. DATE

LS-25