Form LS-87 Nomination of Sheep Industry Board

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FORM APPROVED- OMB NO. 0581-0263
U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

NOMINATIONS TO THE NATIONAL SHEEP INDUSTRY IMPROVEMENT CENTER BOARD

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unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0581-026. 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.

1. STATE/UNIT

NAMES(S) OF NOMINEE(S)
(List name(s) for each allotted position on the Board)

IF MORE SPACE IS NEEDED, USE ADDITIONAL FORMS.
A COMPLETED BACKGROUND INFORMATION SHEET SIGNED BY EACH NOMINEE MUST BE ATTACHED.

2. IDENTIFICATION OF PERSON AND ORGANIZATION/ASSOCIATION SUBMITTING THESE NOMINATIONS
A. NAME AND ADDRESS OF ORGANIZATION/ASSOCIATION

C. NAME AND TITLE (PRINT OR TYPE)

D. E-MAIL ADDRESS ([email protected])

B. FACSIMILE NO. AND AREA CODE

E. SIGNATURE

RETURN FORMS TO: 5HVHDUFKDQG3URPRWLRQ'LYLVLRQ
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U.S. Department of Agriculture, Room 268-S
1400 Independence Avenue, SW, MAIL STOP 0251
Washington, DC 20250-0251
FAX: 202/720-1125
LS-87 (07-13)

DATE