MUS-NBF Mushrooms Ballot

OMB No. 0581-0093

Mushroom Promotion, Research, and Consumer Information Order

Mail Ballot - Region #:

ELECTION OF NOMINEES TO SERVE ON THE MUSHROOM COUNCIL

Please read and complete all sections of this ballot. When voting, vote for ONLY one candidate by placing an "X" next to the Candidate's name. This ballot must be received not later than . All information on this ballot shall be kept strictly confidential in accordance with the requirements of 7 CFR Part 1209.62. Late or incomplete ballots will be invalid and will not be counted.

I. Ballot:

I Favor the Following Candidate to serve a three year term on the Mushroom Council: (Select one only).

( )

( )

( )

( ) (write in)

II. Certification:

I hereby CERTIFY that during the period _ , through , I produced on average, ____________________ pounds of mushrooms for fresh use within the region. 1/2

Business Name Business address - Number and Street

(If individually owned, list name of sole proprietor.

If a partnership, corporation, association, or cooperative,

list name of business entity.) City, Town

Name of Individual Voting State Zip Code

(Area Code) Business Telephone Number

Signature of Individual Voting Title of Individual Voting

1/ The term "on average" shall be calculated by adding the voter's , through __ , production with the voter's ____ through , production and dividing by two. For example, if the voter’s , through , production was 1,000,000 pounds and the voter's through , production was 2,000,000 pounds. The total for the period is 3,000,000 pounds making the voter's "on average" production 1,500,000 pounds.

2/ Any false statement or misrepresentation may result in a fine of not more than $10,000, or imprisonment for not more than 5 years, or both (18 U.S.C. 1001).

MUS-NBF (rev. 02/11) Destroy previous version.

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.

MUS-NBF (02/11) Destroy previous version.