Collecting Handler Registration Statement

OMB NO. 0581-0093

EGG RESEARCH AND PROMOTION ORDER

Collecting Handler Registration Statement

RETURN TO: AMERICAN EGG BOARD 1460 RENAISSANCE DRIVE PARK RIDGE, ILLINOIS 60068 PHONE: (847) 296-7043	FOR OFFICE USE ONLY - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - IDENTIFICATION NUMBER
BUSINESS NAME AND ADDRESS (City, State, and ZIP Code)	□ CORPORATION □ PARTNERSHIP □ OTHER: ___________________ ------------------------------------------------------------------------ TELEPHONE NUMBER (Include Area Code)
NAME(S) OF INDIVUDUAL(S) RESPONSIBLE FOR FILING AND CERTIFICATION OF REPORTS WITH AMERICAN EGG BOARD _________________________________________________ _________________________________________________ NAME TITLE _________________________________________________ _________________________________________________ NAME (If corporation, please list name of president) TITLE
TYPE OF REPORTING PERIOD (Please check one): IMPORTANT: Date you first handled eggs ________________ □ 1. CALENDAR MONTH ACCOUNTING PERIOD □ 2. FOUR-WEEK ACCOUNTING PERIOD (13 EQUAL 4-WEEK PERIODS PER YEAR) (Give starting date of four-week accounting period _______________________) (Sunday) □ 3. TWELVE ACCOUNTING PERIODS ANNUALLY ON FOUR-WEEK, FOUR-WEEK, FIVE-WEEK CYCLES. (Give starting dates of first six periods:) 1. Four-weeks beginning __________________ (Sunday) 2. Four-weeks beginning __________________ (Sunday) 3. Five-weeks beginning __________________ (Sunday) 4. Four-weeks beginning __________________ (Sunday) 5. Four-weeks beginning __________________ (Sunday) 6. Five-weeks beginning __________________ (Sunday) _________________________________________________________________________________________________ _________________________________________________________________________________________________
SIGNATURE	TITLE	DATE

Required by Public Law 93-428, The Egg Research and Consumer Information Act (as Amended by Public Law 96-276).

BURDEN AND NONDISCRIMINATION STATEMENT

The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 522a)

and the Paperwork Reduction Act of 1995, as amended. The authority for requesting this

information to be supplied on this form is the Commodity Promotion, Research, and Information Act of 1996, Pub. L. 104-127, 110 Stat.1032 (7 U.S.C. 7411-7425). Furnishing the requested information is necessary for the administration of this program. Submission of Tax Identification Number (TIN) or Employer Identification Number (EIN) is mandatory, and will be used to determine affiliation or entity identification”.

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 10 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.