OMB Approval No. 0581-0071

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ALMOND BOARD OF CALIFORNIA
1150 9th Street, Suite 1500
Modesto, CA  95354
Tel: (209) 549-8262 Fax: (209) 550-5494

ACCEPTED USER BUSINESS DATA SHEET

Name: 	

Mailing Address: 	

Street Address: 	

Facility Location: 	

Telephone Number: ____________________________	Fax Number: _______________________________

Email Address: ________________________________	SSN or EIN: ________________________________

	
Business/Organization Type:		Years in Business: __________
□ Sole Proprietor
□ Partnership
□ Corporation

Names and Titles of Principals (Persons owning/managing the business):
	
	
	
	

Check box that applies to Principals:
Almond Grower:		□ Yes		□ No		Handler:		□ Yes		□ No

If growers, please provide number of acres and location of orchards 	
	
	

Bank Reference 	


The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 552a) and the Paperwork Reduction Act of 1995, as amended.  The authority for requesting the information to be supplied on this form is the Agricultural Marketing Agreement Act of 1937, Secs. 1-19, 48 Stat. 31, as amended, (7 U.S.C. 601-674).  Furnishing the requested information is necessary for the administration of the marketing order program.  Submission of the Tax Identification Number (TIN) is mandatory, and will be used to validate ballots and determine affiliation or entity identity.  Please note that ballots will not become invalid if a TIN is not disclosed.

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 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.  

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.