No Form Number AEB Certification Request

E GG CERTIFICATION REQUEST FORM

This form is to be completed by producer organizations wishing to nominate members or alternate members for appointment to the American Egg Board.

All items must be fully answered. If additional space is needed to complete your response, please attach separate sheets of paper. Please print or type.

1. Please provide the following information:

(Name of Organization)

(Street Address or P.O. Box No.)

(City) (State) (Zip Code)

(Area Code) (Telephone Number) (Fax Number, if applicable)

2. Geographic area covered by the organization’s active membership:

If the geographic area is other than national or Statewide, please describe the area covered:

3. Describe the nature and size of the organization’s active membership including the proportion of the total active membership accounted for by producers of commercial eggs:

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4. Include a chart or map showing the egg production by State in which the organization

has members, and the volume of commercial eggs produced by the organization’s active membership in such State(s):

5. Describe the extent to which the commercial egg producer membership of the

organization is represented in setting the organization’s policies:

6. Indicate evidence of stability and permanency of the organization (i.e. number of years

in existence and the number of members during each of the last 5 years):

7. List sources from which the organization’s operating funds are derived:

8. Describe the functions of the organization:

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9. Describe the organization’s ability and willingness to further aims and objectives of the Act:

10. I hereby certify that the information provided in this form is true, complete and correct:

(Your Name) (Your Signature)

(Your Title) (Date)

Return this form to: Poultry Programs, Room 3932-S

Agricultural Marketing Service

U.S. Department of Agriculture

1400 Independence Ave., SW., Stop 0256

Washington, DC 20250-0256

For this certification form to be considered, it must be received by the

Department no later than ____________________.

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 0581-0093. 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.