No Form number CA Date (Committee Nomination Form)

OMB No. 0581-0178

CALIFORNIA DATE ADMINISTRATIVE COMMITTEE

P.O. Box 1736

Indio, CA 92202-1736

Tel: (760) 347-4510 Fax: (760) 347-6374

NOMINATION FOR MEMBERSHIP

I,

representing (name of firm)

located at ,

a Riverside County □ Producer □ Producer-Handler (check the appropriate category), nominate the following person(s) to serve as Producer or Producer-Handler representative(s) for the California Date Administrative Committee (Committee):

Name		Mailing Address		Phone Number

Signature: ____________________________________ Date: ___________________________

NOTE: Producers may only nominate Producer nominees. Producer-Handlers may only nominate Producer-Handler nominees.

Completed nomination forms must be received by the Committee no later than May ___, 20___ in order to be valid. They may be mailed or faxed to the Committee at the address above, or delivered to the Committee at USDA Service Center, 82-901 Bliss Avenue, Indio, CA.

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 0581-0178. 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 of 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, political beliefs, genetic information, 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.

(Rev. 01/2014) Destroy previous editions.