920-Kiwifruit Official Nomination Form

OMB No. 0581-1089

KIWIFRUIT ADMINISTRATIVE COMMITTEE

OFFICIAL NOMINATION FORM

DISTRICT #_____

Listed below are the incumbent Kiwifruit Administrative Committee (Committee) members for this district:

SEAT 1: Incumbent Member: _______________________________________

Incumbent Alternate Member: _______________________________

SEAT 2: Incumbent Member: _______________________________________

Incumbent Alternate Member: _______________________________

We ask that you be mindful of the U.S. Department of Agriculture’s policy regarding Equal Employment Opportunity and Civil Rights and consider eligible women, minorities, and persons with a disability for membership on the Committee. We also ask that you be mindful of the Department’s policy regarding outreach to new members and small business entities. If you would like to nominate a grower, or their employee, and are unsure if they qualify in your district, please call our office at (916) 441-0678. Nomination forms must be postmarked no later than _____________________________, 20____.

PLEASE PRINT THE NAME OF YOUR NOMINEE(S) IN THE SPACE PROVIDED BELOW. TO BE ELIGIBLE TO SERVE ON THE COMMITTEE, A NOMINEE MUST CURRENTLY BE PRODUCING KIWIFRUIT FOR MARKET, OR BE AN EMPLOYEE OF A CURRENT PRODUCER. ALL QUALIFIED NOMINEES FOR EACH POSITION WILL APPEAR ON THE FORTHCOMING BALLOT TO BE MAILED TO ALL KIWIFRUIT GROWERS, RESPECTIVE OF DISTRICTS.

SEAT 1:

MEMBER NOMINEE:

NAME ________________________________________________________________

ALTERNATE MEMBER NOMINEE:

NAME ________________________________________________________________

SEAT 2:

MEMBER NOMINEE:

NAME ________________________________________________________________

ALTERNATE MEMBER NOMINEE:

NAME ________________________________________________________________

Nominator's Comments: (use reverse side of form if more space is required)

_________________________________________________________________________________________________

_________________________________________________________________________________________________

NOMINATOR’S CERTIFICATION STATEMENT: I certify that I am currently a kiwifruit grower and that to the best of my knowledge, the above nominees are currently kiwifruit growers or employees of growers in this district.

Signature: __________________________________________________________________________________

Name: ________________________________________ Phone No.: __________________________

Address: __________________________________________________________________________________________

PLEASE COMPLETE THE NOMINATION FORM AND RETURN IT IN THE ENCLOSED PRE-ADDRESSED ENVELOPE TO THE COMMITTEE. INCOMPLETE FORMS OR FORMS POSTMARKED LATER THAN __________________, 20___ MAY BE INVALIDATED. PLEASE CALL THE COMMITTEE AT (916) 441-0678 IF YOU HAVE ANY QUESTIONS.

NOTE: 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 0581-0189. The time required to complete this information collection is estimated to average 10 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.

KIWIFRUIT ADMINISTRATIVE COMMITTEE

DISTRICT #_____

CANDIDATE STATEMENTS

Candidate Name, Member Candidate, Seat 1

(Statement)

Candidate Name, Alternate Member Candidate, Seat 1

(Statement)

Candidate Name, Member Candidate, Seat 2

(Statement)

Candidate Name, Alternate Member Candidate, Seat 2

(Statement)

Rev. 7/10. Destroy previous editions.