DA-19 Dairy Nomination Form

Reproduce locally. Include form number and date on all reproductions. Approved OMB No. 0581-0093

U.S. DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

DAIRY PROGRAMS

NOMINATION OF MILK PRODUCERS OR IMPORTERS TO SERVE ON THE NATIONAL DAIRY PROMOTION AND RESEARCH BOARD

(Under the Dairy Production Stabilization Act of 1983 and the Dairy Promotion and Research Order (7 CFR 1150.101 et seq.))

The Dairy Promotion and Research Order (Order) provides that producer and farm organizations, and importer and importer organizations may nominate milk producers or dairy product importers to serve on the National Dairy Promotion and Research Board. Each producer and importer organization may submit to the Secretary nomination(s) for each appointment to be made as defined in Section 1150.131 of the Order in which the organization represents producers or importers. The nominee must be a milk producer located in the region such person is to represent, or a dairy product importer.

Attach a separate sheet if additional space is needed. Please submit a separate form for each nominee.

NAME OF NOMINEE

PLEASE IDENTIFY:

 Producer Nominee -- Region number ______

 Importer Nominee

If any nominee(s) is named as a result of a caucus of organizations representing milk producers in the same region or importers, identify the nominee(s) and list for each the names and addresses of the organizations participating in the caucus.

NOMINEE(S)

NAMES AND MAILING ADDRESSES OF ORGANIZATIONS

NAME AND MAILING ADDRESS OF ORGANIZATION SUBMITTING THIS NOMINATION FORM

NAME OF RESPONDING OFFICIAL (PRINT)

SIGNATURE

TITLE OF RESPONDING OFFICIAL (PRINT)

DATE

RETURN ORIGINAL TO: USDA, AMS, DAIRY PROGRAMS

PROMOTION AND RESEARCH BRANCH

STOP 0233, ROOM 2958-SOUTH

1400 INDEPENDENCE AVENUE, S.W.

WASHINGTON, D.C. 20250-0233

FORM DA-19 (6-07) (Destroy all previous editions)

According to the Paperwork Reduction Act of 1995, an agency my 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 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.

Information is collected to obtain names of nominees for appointment as members of the Board. Response is voluntary (7 CFR 1150.133).

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.