FV-270 Nomination of Popcorn Processors

REPRODUCE LOCALLY. Include form number and date on all reproductions. _{Form Approved - OMB No. 0581-0093}

U.S. DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE FRUIT AND VEGETABLE PROGRAMS

NOMINATION OF POPCORN PROCESSORS TO SERVE ON THE POPCORN BOARD

Information is collected to obtain names of nominees for appointment as members of the Board. Response is voluntary (7 CFR 1215).

(Under the Popcorn Promotion, Research, and Consumer Information Act and the Popcorn Promotion, Research, and Consumer Information Order (7 CFR 1215).)

The Popcorn Promotion, Research, and Consumer Information Order provides that popcorn processors may nominate eligible popcorn processors to serve on the Popcorn Board. Each popcorn processor may submit to the Popcorn Board nomination(s) for each vacancy. Popcorn processors of more than 4 million pounds annually are eligible to nominate and be appointed to the Popcorn Board. No more than one officer or employee of a processor may serve as a Board member at the same time.

SECTION I - NOMINEE (S) (Type or print only.)

NAME _TITLE

_{COMPANY NAME}

WEBSITE URL

_{MAILING ADDRESS}

CITY	STATE	ZIP CODE
TELEPHONE NUMBER (Include Area Code)	FAX NUMBER (Include Area Code)	E-MAIL
NAME	TITLE

_{COMPANY NAME}

_{WEBSITE URL}

_{MAILING ADDRESS}

CITY	STATE	ZIP CODE
TELEPHONE NUMBER (Include Area Code)	FAX NUMBER (Include Area Code)	E-MAIL
NAME	TITLE

_{COMPANY NAME}

_{WEBSITE URL}

_{MAILING ADDRESS}

CITY	STATE	ZIP CODE
TELEPHONE NUMBER (Include Area Code)	FAX NUMBER (Include Area Code)	E-MAIL

FV 270 (12-13) Destroy previous editions. (See reverse of form for Privacy Act Statement.)

SECTION II - PROCESSORS SUBMITTING THIS NOMINATION FORM (Type or print only.)

_{NAME TITLE}

_{COMPANY NAME}

_{WEBSITE URL}

_{MAILING ADDRESS}

CITY	STATE	ZIP CODE
TELEPHONE NUMBER (Include Area Code)	FAX NUMBER (Include Area Code)	E-MAIL

_{SECTION III - CERTIFICATION STATEMENT}

I CERTIFY that during the period of January 1, 20 , through December 31, 20 , I processed pounds of popcorn. (This information provided shall be treated as strictly

confidential.)

I further CERTIFY that the information contained in this certification section of this nomination form is true, complete, and correct to the best of my knowledge and belief, and is made in good faith. If this nomination form is being submitted on behalf of any group of individuals, partnership, corporation, or other business entity

engaged in the processing of popcorn, I also CERTIFY that I have the authority to submit this nomination form and will submit evidence thereof if so requested by the Popcorn Board or the Department of Agriculture.

_SIGNATURE ^DATE

SECTION IV - MAILING ADDRESS

_{MAIL TO:} The Popcorn Board

ATTN: Genny Bertalmio

330 North Michigan Avenue, Suite 2000

Chicago, Illinois 60611

FAX No: (312) 821-0202

Telephone No: (312) 673-4883

E-mail: [email protected]

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.

FV 270 (12-13) REVERSE