LS-45-R Soybean Nomination Form

Print Form
REPRODUCE LOCALLY. Include form number on all reproductions.

FORM APPROVED- OMB NO. 0581-0093

U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

NOMINATION OF SOYBEAN PRODUCERS FOR APPOINTMENT TO THE UNITED SOYBEAN BOARD
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.

Pursuant to the Promotion, Research and Consumer Act, the following names of soybean producers are submitted as 1. STATE/UNIT
nominees to the United Soybean Board as representatives of the indicated state.

NAMES(S) OF NOMINEE(S)
(List name(s) for each allotted position on the Board)

IF MORE SPACE IS NEEDED, USE ADDITIONAL FORMS. A COMPLETED BACKGROUND INFORMATION
SHEET SIGNED BY EACH NOMINEE MUST BE ATTACHED.

3. IDENTIFICATION OF PERSON AND ORGANIZATION/ASSOCIATION SUBMITTING THESE NOMINATIONS
NAME AND ADDRESS OF ORGANIZATION/ASSOCIATION

NAME AND TITLE (PRINT OR TYPE)

E-MAIL ADDRESS ([email protected])

FACSIMILE NO. AND AREA CODE

RETURN FORMS TO:

LS-45-R

SIGNATURE

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

DATE