DA-19-1 Fluid Milk Nomination Form

Reproduce locally. Include form number and date on all reproductions.

Approved OMB No. 0581-0093

U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

DAIRY PROGRAMS
NOMINATION OF MILK PROCESSORS TO SERVE ON THE NATIONAL FLUID MILK PROCESSOR PROMOTION BOARD
(Under the Fluid Milk Promotion Act of 1990, as amended, and the Fluid Milk Promotion Order (7 CFR 1160. 101 et seq.))
The Fluid Milk Promotion Order provides that individual fluid milk processors and other interested parties, including eligible organizations, may nominate milk processors
to serve on the National Fluid Milk Processor Promotion Board. Fluid milk processors and other interested parties may nominate milk processors for regions in which
they are located or market fluid milk, and for the at-large members. Eligible organizations may submit a slate of nominees for seats in all regions and for at-large members.
Except for the member or members from the general public, nominees shall be active owners or employees of a fluid milk processor.
Attach a separate sheet if additional space is needed. Please submit a separate form for each nominee.

NAME, BUSINESS ADDRESS, AND TELEPHONE NUMBER OF NOMINEE

Regional Nominee ---

Number of Region

At-large Processor Nominee

General Public Nominee
NAME AND MAILING ADDRESS OF FLUID MILK PROCESSOR, INTERESTED PARTY OR ELIGIBLE ORGANIZATION SUBMITTING NOMINATION

NAME AND EMAIL OF RESPONDING OFFICIAL (PRINT or TYPE)

SIGNATURE

EMAIL:
TITLE OF RESPONDING OFFICIAL (PRINT or TYPE)

RETURN ORIGINAL TO:

DATE

USDA, AMS, DAIRY PROGRAMS
PROMOTION AND RESEARCH BRANCH
STOP 0233, ROOM 2958-SOUTH
1400 INDEPENDENCE AVENUE, S.W.
WASHINGTON, D.C. 20250-0233

FORM DA-19-1 (Rev. 02/17) (Destroy all previous editions)
According to the Paperwork Reduction Act of 1995, an agency my 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. Information is collected to obtain names of nominees for appointment as members of the Board. Response is voluntary (7 CFR 1150.133).
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.