Form Approved – OMB No. 0581-0093
INSTRUCTIONS:
The nominees listed on this ballot are seeking seats on the Softwood Lumber Board (Board) representing the _______ Region. The _______ Region consists of _______________.
You are asked to cast your vote for __ (#) members for the above seat(s) on the Board.
If you domestically manufacture and ship softwood lumber from more than one region within the United States (or import if importer ballot), you may only cast one ballot in the region of your choice.
If you are both a domestic manufacturer and importer of softwood lumber, you may only cast one ballot as either a domestic manufacturer or an importer.
Please call the Softwood Lumber Board at XXX-XXX-XXXX if you have any questions.
Please complete this ballot AND certification statement and mail it back to the Board in the enclosed, self-addressed envelope. Ballots must be received by the Board by (specify date). Ballots postmarked after that date will not be counted.
FALSIFICATION OF INFORMATION OR MISREPRESENTATION OF IDENTITY ON THIS GOVERNMENT DOCUMENT MAY RESULT IN A FINE OF NOT MORE THAN $10,000, OR IMPRISONMENT FOR NOT MORE THAN FIVE YEARS, OR BOTH.
(18 U.S.C. 1001)
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 15 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.
SOFTWOOD LUMBER BOARD
BALLOT – __________ REGION
Choose ___ (#) candidates only.
CANDIDATES
[ ] Name, company, state/province
[ ] Name, company, state/province
[ ] Name, company, state/province
[ ] ________________________________________(Write in)
Print Candidate Name
PLEASE BE SURE TO COMPLETE THE FOLLOWING CERTIFICATION STATEMENT:
I certify that I domestically manufactured and shipped within the United States or imported to the United States a minimum of 15 million board feet of softwood lumber during the twelve-month period of (date) through (date) and that I manufactured and domestically shipped or imported softwood lumber from the ________Region:
Signature: ____________________________________________________________
Print Name: ___________________________________________________________
Company/Entity:__________________________________________________
Phone: ____________________________
Submission of Ballot to Board
Once you have completed and signed this ballot please place this ballot in the enclosed, self-addressed envelope and mail it to the Board. Unsigned or incomplete ballots, or ballots postmarked after
(date) will not be counted.
SWL-BAL (12/13) Destroy previous edition.
| File Type | application/msword |
| File Title | Form Approved – OMB No |
| Author | FV_Profile |
| Last Modified By | USDA |
| File Modified | 2013-12-30 |
| File Created | 2013-12-30 |