No Form number CA Almonds Accepted User Business Data Sheet

OMB No. 0581-0178

ALMOND BOARD OF CALIFORNIA

1150 9th Street, Suite 1500

Modesto, CA 95354

Tel: (209) 549-8262 Fax: (209) 550-5494

ACCEPTED USER BUSINESS DATA SHEET

Name:

Mailing Address:

Street Address:

Facility Location:

Telephone Number: ____________________________ Fax Number: _______________________________

E-mail Address: _______________________________ SSN or EIN: ________________________________

Business/Organization Type: Years in Business: __________

□ Sole Proprietor

□ Partnership

□ Corporation

Names and Titles of Principals (Persons owning/managing the business):

Check box that applies to Principals:

Almond Grower: □ Yes □ No Handler: □ Yes □ No

If growers, please provide number of acres and location of orchards

Bank Reference

The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 552a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting the information to be supplied on this form is the Agricultural Marketing Agreement Act of 1937, Secs. 1-19, 48 Stat. 31, as amended, (7 U.S.C. 601-674). Furnishing the requested information is necessary for the administration of the marketing order program. Submission of the Tax Identification Number (TIN) is mandatory, and will be used to validate ballots and determine affiliation or entity identity. Please note that ballots will not become invalid if a TIN is not disclosed.

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 0581-0178. 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.

Rev. 10/2010. Destroy previous Editions.