XMAS-NF Nomination for Appointment to the Christmas Tree Promoti

OMB No. 0581-0268

NOMINATION FOR APPOINTMENT TO THE CHRISTMAS TREE PROMOTION BOARD

CHRISTMAS TREE PROMOTION, RESEARCH AND INFORMATION ORDER

(7 CFR PART 1214)

The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 552a) and the Paperwork Reduction Act of 1995. 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 the Tax Identification Number is mandatory, and will be used to determine affiliation or entity identification.

Names of Nominees and Position (Producer or Importer and the REGION) for which each person is nominated. Nominees must meet eligibility requirements as described in §§ 1214.40 and 1214.41 of the Order. Nominees must also domestically cut and sell or import more than 500 Christmas trees during the fiscal year. Producers who cut and sell Christmas trees in more than one region may seek nomination in only one region of their choice. The regions are as follows: Western Region, Central Region, Eastern Region or Importer (please specify).

Nominee Name ________________________________________ Region_______________________

Address:

Name of Person or Organization submitting these nominations

Name of Organization/Person: _______________________________________ Tax ID/Bus.#________________

Address: ___________________________________________________________________________________

City: _________________________ State: ________________ Zip: __________________

Phone No. ______________________ Fax No. _____________________

E-Mail: ________________________

Print Name and Title of Person Completing this Nomination

________________________________________________________________________________________________________

Signature Date

Return Original Forms to: Christmas Tree Promotion Board

Street, City, State, Zip Code

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 0581-0268. 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.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: 1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; 2) fax: (202) 690-7442; or 3) email: [email protected].

USDA is an equal opportunity provider, employer, and lender.

XMAS-NF (02/17) Destroy previous version.