MAN-BAL Mangos Importer Nomination Ballot

OMB No. 0581-0093

NATIONAL MANGO BOARD (7 CFR 1206)
IMPORTER NOMINATION BALLOT
The nominees listed on this ballot are seeking a seat on the National Mango Board (NMB). As a
mango importer, you are asked to vote for candidates in District (X). There are X positions
available for District X. The individual receiving the highest vote totals will be considered the firstchoice of the industry for the vacant position and the next one will be considered the secondchoice for the position. Please mark your selections and completely fill in the information
requested.
Mail this ballot for it to be received by NMB on or before
received after this date will not be counted.

XX, 20XX. Submissions

NATIONAL MANGO BOARD
Street
City, State Zip Code
Please select XXX names from the list of nominees for District I:
XXXX 

XXXX 

XXXX 

XXXX 

Please select XXX names from the list of nominees for District II:
XXXX 

XXXX 

XXXX 

XXXX 

Please select XXX names from the list of nominees for District III:
XXXX 

XXXX 

XXXX 

XXXX 

Please select XXX name from the list of nominees for District IV:
XXXX 

XXXX 

XXXX 

XXXX 
Certification Statement

I certify that I imported 500,000 pounds or more of Mangos at the location listed below during the
twelve-month period of January 1, 20XX through December 31, 20XX.
(Please type or print)

Company/Business Name:________________________________________________________
Name:________________________________________________________________________
Title:__________________________________________________________________________
Address: ______________________________________________________________________
City: _______________________________ State: _______________ Zip code: ______________
Signature: __________________________________ Date: ___________________
(Continued on Back Page)

MAN-BAL (Rev. 03/17) Destroy previous editions.
(Importer)

OMB No. 0581-0093

DIVERSTIY STATEMENT
The National Mango Board (NMB) encourages industry members without regard to race,
color, national origin, sex, religion, age, disability, political beliefs, sexual orientation, size of
business/operation, and marital or family status or other basis protected by U.S. law to
participate in NMB activities and seek a position on the NMB.

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 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.

MAN-BAL (Rev. 03/17) Destroy previous editions.
(Importer)