DA-19 Dairy Nomination Form

Reproduce locally. Include form number and date on all reproductions. Approved OMB No. 0581-0093

U.S. DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE DAIRY PROGRAMS
NOMINATION OF MILK PROCESSORS TO SERVE ON THE NATIONAL FLUID MILK PROCESSOR PROMOTION BOARD (Under the Fluid Milk Promotion Act of 1990, as amended, and the Fluid Milk Promotion Order (7 CFR 1160.101 et seq.))
The Fluid Milk Promotion Order provides that individual fluid milk processors and other interested parties, including eligible organizations, may nominate milk processors to serve on the National Fluid Milk Processor Promotion Board. Fluid milk processors and other interested parties may nominate milk processors for regions in which they are located or market fluid milk, and for the at-large members. Eligible organizations may submit a slate of nominees for seats in all regions and for at-large members. Except for the member or members from the general public, nominees shall be active owners or employees of a fluid milk processor. Attach a separate sheet if additional space is needed. Please submit a separate form for each nominee.
NAME, BUSINESS ADDRESS, AND TELEPHONE NUMBER OF NOMINEE
		 Regional Nominee --- _____ Number of Region  At-large Processor Nominee  General Public Nominee
NAME AND MAILING ADDRESS OF FLUID MILK PROCESSOR, INTERESTED PARTY OR ELIGIBLE ORGANIZATION SUBMITTING NOMINATION
NAME AND EMAIL OF RESPONDING OFFICIAL (PRINT or TYPE) EMAIL:_______________________________________	SIGNATURE
TITLE OF RESPONDING OFFICIAL (PRINT or TYPE)	DATE
RETURN ORIGINAL TO: USDA, AMS, DAIRY PROGRAMS PROMOTION AND RESEARCH BRANCH STOP 0233, ROOM 2958-SOUTH 1400 INDEPENDENCE AVENUE, S.W. WASHINGTON, D.C. 20250-0233

FORM DA-19-1 (6/10) (Destroy all previous editions)

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. Information is collected to obtain names of nominees for appointment as member of the Board. Response is voluntary (7 CFR 1160.202).

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