PAP-NOM (Order) Nomination for Appointment to the Paper & Paper-Based Pa

OMB No. 0581-NEW

NOMINATION FOR APPOINTMENT TO THE PAPER & PAPER-BASED PACKAGING BOARD

PAPER AND PAPER-BASED PACKAGING PROMOTION, RESEARCH AND INFORMATION ORDER

(7 CFR PART 1222)

The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 552a) and the Paperwork Reduction Act of 1995. The authority for requesting this information to be supplied on this form is the Commodity Promotion, Research, and Information Act of 1996, Pub. L. 104-127, 110 Stat. 1032 (7 U.S.C. 7411-7425). Furnishing the requested information is necessary for the administration of this program. Submission of the Tax Identification Number is mandatory, and will be used to determine affiliation or entity identification.

Names of Nominees and Position (Domestic Manufacturer or Importer and the REGION) for which each person is nominated. Nominees must meet eligibility requirements as described in §§ 1222.40 and 1222.41 of the Order. Nominees that are both domestic manufacturer and importer must seek nomination for one and not both. Domestic manufacturers must manufacture paper and paper-based packaging in the region for which they seek nomination. Nominees that manufacture in more than one region may seek nomination in one region of their choice. The regions are as follows: South, Northeast, Midwest, West and Importers (please specify).

Nominee Name ________________________________________ Region_______________________

Did you manufacture between 100,000 and 250,000 short tons? ( ) Yes or ( ) No

Address:

Name of Person or Organization submitting these nominations

Name of Organization/Person: _______________________________________ Tax ID/Bus. #________________

Address: ___________________________________________________________________________________

City: _________________________ State: ________________ Zip: __________________

Phone No. ______________________ Fax No. _____________________

E-Mail: ________________________

Print Name and Title of Person Completing this Nomination

________________________________________________________________________________________________________

Signature Date

Return Original Forms to: Paper and Paper-Based Packaging Promotion, Research, and Information Board

Street, City, State, Zip Code

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-NEW. The time required to complete this information collection is estimated to average 15 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.

PAP-NOM (02/12)