Electronic Mailing List Subscription Form - Nutrition and Food Safety State, Local, Tribal Government

OMB – 0518-0036

Expires xx/xx/formxxxx

Electronic Mailing List Sign Up Form

How would you like to receive messages from the list?

___ Regular Subscription – you receive each message as it is sent to the list.

___ Digest – receive all messages sent to the list combined into one file that is sent one time each day?

Full Name_________________________________________

Email Address _____________________________________

Confirm Email Address ______________________________

Job Title (be specific) ________________________________

Employer (agency, organization, company)__________________________________________________

Mailing Address (street, city, state, Zip Code) ________________________________________________

Telephone: ___________________________________________________________________________

Persons that work with certain US Department of Agriculture Food and Nutrition Service Programs may join this list. Please describe how you are eligible to join this list?

According to the Paperwork Reduction act of 1995, an agency may not conduct or sponsor, and a person is not required to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is OMB 0518-0036. The time required to complete this information will vary based upon one’s relations to the resource being submitted. It is estimated to take 1 minute to complete this entire survey. This includes time for reviewing instruction, researching existing date sources, gathering and maintaining the data needed, and completing and reviewing the collection information. If you need help with this form, please contact us. Email address [email protected]. Telephone number 301-504-6047