No Form Number AEB Egg Certification Request Form

Form Approved. – OMB 0581-0093

EGG CERTIFICATION REQUEST FORM
This form is to be completed by producer organizations wishing to nominate members or alternate members for appointment to the American Egg
Board.

All items must be fully answered. If additional space is needed to complete your response, please attach separate sheets
of paper. Please print or type.

1.

Please provide the following information:

(Name of Organization)

(Street Address or P.O. Box No.)

(City)

(Area Code) (Telephone Number)

2.

(State)

(Zip Code)

(Fax Number, if applicable)

Geographic area covered by the organization's active membership:

If the geographic area is other than national or statewide, please describe the area
covered:

3.

Describe the nature and size of the organization's active membership including the
proportion of the total of active membership accounted for by producers of commercial
eggs:

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4.

Include a chart or map showing the egg production by state in which the organization
has members, and the volume of commercial eggs produced by the organization's active
membership in such state(s):

5.

Describe the extent to which the commercial egg producer membership of the
organization is represented in setting the organization's policies:

6.

Indicate evidence of stability and permanency of the organization (i.e. number of years
in existence and the number of members during each of the last 5 years):

7.

List sources from which the organization's operating funds are derived:

8.

Describe the functions of the organization:

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9.

Describe the organization's ability and willingness to further aims and objectives of the
Act:

10. I hereby certify that the information provided in this form is true, complete and correct:

Print Name

Signature

Title

Date

Return completed form to: Research and Promotion Division

Livestock, Poultry, and Seed Program, AMS
U.S. Department of Agriculture
Street
City, State Zip

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 60 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintain the data needed, and completing and review 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.

LPS (Rev. 04/17)