No Form number Raisin Adm. Cmte. Voluntary Independent Producer Nominat

OMB No. 0581-0178

RAISIN ADMINISTRATIVE COMMITTEE

2445 Capitol Street, Suite 200

Fresno, California 93721

Phone: (559) 225-0520

Fax: (559) 225-0652

VOLUNTARY INDEPENDENT PRODUCER NOMINATION STATEMENT

INSTRUCTIONS: As an independent producer candidate running for office on the Raisin Administrative Committee (RAC) for the _________________ term of office, you have the option to provide the information below. The information will be compiled and included with the ballots that will be mailed to independent producers. Please return this form to the RAC by mail or fax no later than ___________________, 20___.

Date: __________________________

Name:

Telephone Number:

E-mail Address:

Are you a producer? □ Yes □ No

What is your affiliation with a packing operation (none, employee, owner, etc.):

Producer’s Statement (Explanation of your qualifications and desire to represent independent producers on the RAC. Attach an additional sheet if necessary.):

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 5 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.