FV-270 Nomination of Popcorn Processors

REPRODUCE LOCALLY. Include form number and date on all reproductions.
U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
FRUIT AND VEGETABLE PROGRAMS

NOMINATION OF POPCORN PROCESSORS TO SERVE
ON THE POPCORN BOARD

Form Approved - OMB No. 0581-0093

Information is collected to obtain names of nominees for appointment
as members of the Board. Response is voluntary (7 CFR 1215).
(Under the Popcorn Promotion, Research, and Consumer Information
Act and the Popcorn Promotion, Research, and Consumer Information
Order (7 CFR 1215).)

The Popcorn Promotion, Research, and Consumer Information Order provides that popcorn processors may nominate eligible popcorn
processors to serve on the Popcorn Board. Each popcorn processor may submit to the Popcorn Board nomination(s) for each vacancy.
Popcorn processors of more than 4 million pounds annually are eligible to nominate and be appointed to the Popcorn Board. No more
than one officer or employee of a processor may serve as a Board member at the same time.
SECTION I - NOMINEE (S) (Type or print only.)
NAME

TITLE

COMPANY NAME

WEBSITE URL

MAILING ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NUMBER (Include Area Code)

FAX NUMBER (Include Area Code)

E-MAIL

NAME

TITLE

COMPANY NAME
WEBSITE URL

MAILING ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NUMBER (Include Area Code)

FAX NUMBER (Include Area Code)

E-MAIL

NAME

TITLE

COMPANY NAME

WEBSITE URL

MAILING ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NUMBER (Include Area Code)

FAX NUMBER (Include Area Code)

E-MAIL

FV 270 (08-10) Destroy previous editions.

(See reverse of form for Privacy Act Statement.)

SECTION II - PROCESSORS SUBMITTING THIS NOMINATION FORM (Type or print only.)
NAME

TITLE

COMPANY NAME

WEBSITE URL

MAILING ADDRESS

CITY

STATE

TELEPHONE NUMBER (Include Area Code)

FAX NUMBER (Include Area Code)

ZIP CODE

E-MAIL

SECTION III - CERTIFICATION STATEMENT

I CERTIFY that during the period of January 1, 20 , through December 31, 20 , I processed
___________________ pounds of popcorn. (This information provided shall be treated as strictly
confidential.)
I further CERTIFY that the information contained in this certification section of this nomination form is true,
complete, and correct to the best of my knowledge and belief, and is made in good faith. If this nomination
form is being submitted on behalf of any group of individuals, partnership, corporation, or other business entity
engaged in the processing of popcorn, I also CERTIFY that I have the authority to submit this nomination form
and will submit evidence thereof if so requested by the Popcorn Board or the Department of Agriculture.
DATE

SIGNATURE

SECTION IV - MAILING ADDRESS

MAIL TO:

The Popcorn Board
ATTN: Genny Bertalmio
401 North Michigan Avenue, Suite 2200
Chicago, Illinois 60611
FAX No: (312)527-6783
Telephone No: (312) 673-4883
E-mail: [email protected]

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.
FV 270 (08-10)

REVERSE