DA-19-1 Fluid Milk Nomination Form

Reproduce locally. Include form number and date on all reproductions.
U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

Approved OMB No. 0581-0093

DAIRY PROGRAMS
NOMINATION OF MILK PROCESSORS TO SERVE ON THE NATIONAL FLUID MILK PROCESSOR PROMOTION BOARD
(Under the Fluid Milk Promotion Act of 1990, as amended, and the Fluid Milk Promotion Order (7 CFR 1160.101 et seq.))
The Fluid Milk Promotion Order provides that individual fluid milk processors and other interested parties, including eligible organizations, may nominate milk processors to
serve on the National Fluid Milk Processor Promotion Board. Fluid milk processors and other interested parties may nominate milk processors for regions in which they are
located or market fluid milk, and for the at-large members. Eligible organizations may submit a slate of nominees for seats in all regions and for at-large members. Except for
the member or members from the general public, nominees shall be active owners or employees of a fluid milk processor.
Attach a separate sheet if additional space is needed. Please submit a separate form for each nominee.

NAME, BUSINESS ADDRESS, AND TELEPHONE NUMBER OF NOMINEE

Regional Nominee --- _____ Number of Region

At-large Processor Nominee

General Public Nominee
NAME AND MAILING ADDRESS OF FLUID MILK PROCESSOR, INTERESTED PARTY OR ELIGIBLE ORGANIZATION SUBMITTING NOMINATION

NAME AND EMAIL OF RESPONDING OFFICIAL (PRINT or TYPE)

SIGNATURE

EMAIL:_______________________________________
TITLE OF RESPONDING OFFICIAL (PRINT or TYPE)

RETURN ORIGINAL TO:

DATE

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-19-1 (6/07) (Destroy all previous editions)
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 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 member of the Board. Response is voluntary (7
CFR 1160.202).
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.