Application for Certification of Organization

OMB No. 0581-0093

APPLICATION FOR CERTIFICATION OF ORGANIZATION

HONEY PACKERS AND IMPORTERS RESEARCH, PROMOTION,

CONSUMER EDUCATION AND INDUSTRY INFORMATION ORDER

(7 CFR PART 1212)

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).

1. Please mark an “X” in the appropriate block for which organization or association you are applying for certification: (Mark only one box. If you are applying for more than one group below, a separate form must be filled out for each group.)

[ ] Producers [ ] Importers [ ] First Handlers [ ] Marketing Cooperative

2. Name of Organization: _________________________________________________ Tax ID# __________________

Address: _______________________________________________________________________________________

City: _________________________ State: ________________ Zip: __________________

Phone No. _______________________ Fax No. ______________________ E-Mail: ________________________

3. Total Members in most recent calendar year: _________________

4. What percent of your members are considered producers _________; handlers ___________; importers __________?

5. What is the Volume of Honey or Honey Products that the Association represents (pounds)? ___________________

6. If producer or handler organization: Does your organization represent a substantial number of producers or handlers who produce or market a substantial volume of honey or honey products in at least 20 States? If yes, list States.

7. If importer organization: What percent of the total volume of honey or honey products imported in the U.S. do your members represent? (pounds and percent of total) _____________ pounds __________ percent of total imports

8. List of Source(s) from which your organization operating funds are derived: _______________________________

___________________________________________________________________________________________

9. Describe purpose/function of the organization: _____________________________________________________

___________________________________________________________________________________________

10. Describe the organization’s ability and willingness to further the purpose and objectives of the Honey Packer and Importer Order: ________________________________________________________________________________

_____________________________________________________________________________________________

CERTIFICATION AND SIGNATURE

I hereby certify that: (1) an interest of this organization is in the production or marketing of honey or honey products and (2) the information provided in response to the above items is true, complete, and correct to the best of my knowledge. The organization also agrees to take reasonable steps to publicize to non-members the availability of open Board positions and will consider nominating a non-member if he or she expresses an interest in serving on the Board. 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 eligibility for certification.

____________________________________________________________________

Print Name and Title of Person Completing this Application

________________________________________________________________________________________________________

Signature Date

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IMPORTANT NOTES

NOTE: Information is collected in order to determine eligibility of organizations to nominate producers, importers, first handlers, and honey marketing cooperatives to serve as members of the Honey Packers and Importers Board. Application is voluntary and information is held confidential.

Organizations must apply for certification by the Secretary to be eligible to participate in the making of nomination of honey producers, honey importers, first handlers, and honey marketing cooperatives to serve as members and alternates of the Board as provided in the Honey Packers and Importers Research, Promotion, Consumer Education and Industry Information Order. Information submitted in response to all items must be complete. Please type or print clearly. Send original only to:

Honey Packers and Importers 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 0581-0093. 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.

(rev. 08/10) (Expires XX/XX/XXXX)