Form Approved – OMB No. 0581-0268
The nominees listed on this ballot are seeking seat(s) on the Christmas Tree Promotion Board (Board). You are asked to cast your vote for (number) members for the above seat(s) on the Board. If you domestically cut and sell or import Christmas trees from more than one region, you may only cast a ballot in one region of your choice.
Choose (number) candidates only.
REPRESENTATIVE CANDIDATES
Region ____ (if applicable)
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PLEASE BE SURE TO COMPLETE THE FOLLOWING CERTIFICATION STATEMENT:
I certify that I have (domestically cut and sold/imported) a minimum of 500 Christmas trees during the twelve-month period of Month XX, 20xx to Month XX, 20xx:
Signature: ____________________________________________________________
Print Name: ___________________________________________________________
Company/Organization:__________________________________________________
Address: _____________________________________________________________
City: _______________________ State: ____________ Zip Code: ____________
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. Incomplete ballots, unsigned ballots, or ballots received after Month xx, 20xx, will not be counted.
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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-BL (02/17) Destroy previous version.
| File Type | application/msword |
| File Title | Form Approved – OMB No |
| Author | FV_Profile |
| Last Modified By | Pish, Marylin - AMS |
| File Modified | 2017-03-12 |
| File Created | 2017-03-12 |