MUS-NFC Mushrooms Nomination

OMB No. 0581-0093

Nomination Form

My nomination(s) for candidate(s) in Region _____ are as follows:

1. Name_______________________________	2.Name_______________________________
Company____________________________	Company____________________________
Address_____________________________	Address_____________________________
City, State, Zip_______________________	City, State, Zip_______________________
Phone_______________________________	Phone_______________________________
3. Name_______________________________	4.Name_______________________________
Company____________________________	Company____________________________
Address_____________________________	Address_____________________________
City, State, Zip_______________________	City, State, Zip_______________________
Phone_______________________________	Phone_______________________________

I hereby certify that the company listed below produces over 500,000 pounds of mushrooms annually, on average, for fresh use.

Name:________________________________	Address:______________________________
Title:_________________________________	______________________________________
Company:_____________________________	Phone:________________________________
Signature:_____________________________	Date:_________________________________

See reverse for Burden Statement.

Return Completed form to: Mushroom Council

Street, City, State Zip

(xxx) xxx-xxxx (xxx) xxx-xxxx fax

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.

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.

MUS-NFC (rev. 08/10) Destroy previous editions.