SC-270 Nomination of Popcorn to Serve (Processors)

REPRODUCE LOCALLY. Include form number and date on all reproductions.
U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
FRUIT AND VEGETABLE PROGRAMS

NOMINATION OF POPCORN PROCESSORS TO SERVE
ON THE POPCORN BOARD

Form Approved - OMB No. 0581-0093

Information is collected to obtain names of nominees for appointment
as members of the Board. Response is voluntary (7 CFR 1215).
(Under the Popcorn Promotion, Research, and Consumer Information
Act and the Popcorn Promotion, Research, and Consumer Information
Order (7 CFR 1215).)

The Popcorn Promotion, Research, and Consumer Information Order provides that popcorn processors may nominate eligible popcorn
processors to serve on the Popcorn Board. Each popcorn processor may submit to the Popcorn Board nomination(s) for each vacancy.
Popcorn processors of more than 4 million pounds annually are eligible to nominate and be appointed to the Popcorn Board. No more
than one officer or employee of a processor may serve as a Board member at the same time.
SECTION I - NOMINEE (S) (Type or print only.)
NAME

TITLE

COMPANY NAME

WEBSITE URL

MAILING ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NUMBER (Include Area Code)

FAX NUMBER (Include Area Code)

E-MAIL

NAME

TITLE

COMPANY NAME

WEBSITE URL

MAILING ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NUMBER (Include Area Code)

FAX NUMBER (Include Area Code)

E-MAIL

NAME

TITLE

COMPANY NAME

WEBSITE URL

MAILING ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NUMBER (Include Area Code)

FAX NUMBER (Include Area Code)

E-MAIL

SC 270 (Rev. 03-17) Destroy previous editions.

(See reverse of form for Privacy Act Statement.)

SECTION II - PROCESSORS SUBMITTING THIS NOMINATION FORM (Type or print only.)
NAME

TITLE

COMPANY NAME

WEBSITE URL

MAILING ADDRESS

CITY

STATE

TELEPHONE NUMBER (Include Area Code)

FAX NUMBER (Include Area Code)

ZIP CODE

E-MAIL

SECTION III - CERTIFICATION STATEMENT

I CERTIFY that during the period of January 1, 20
, through December 31, 20
, I processed
pounds of popcorn. (This information provided shall be treated as strictly
confidential.)
I further CERTIFY that the information contained in this certification section of this nomination form is true,
complete, and correct to the best of my knowledge and belief, and is made in good faith. If this nomination form is
being submitted on behalf of any group of individuals, partnership, corporation, or other business entity
engaged in the processing of popcorn, I also CERTIFY that I have the authority to submit this nomination form and
will submit evidence thereof if so requested by the Popcorn Board or the Department of Agriculture.
DATE

SIGNATURE

SECTION IV - MAILING ADDRESS

The Popcorn Board
ATTN: (Name)
Street
City, State, Zip

MAIL TO:

FAX No: (XXX) XXX-XXXX
Telephone No: (XXX) XXX-XXXX
E-mail:
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 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.
SC 270 (Rev. 03-17)

Destroy previous edition.