RAS-BAL Raspberry--Ballot

Form Approved – OMB No. 0581-0093

NATIONAL PROCESSED RASPBERRY COUNCIL
PROCESSED RASPBERRY PROMOTION RESEARCH AND INFORMATION ORDER
BALLOT
The nominees listed on this ballot are seeking seat(s) on the National Processed Raspberry Council
(Council). You are asked to cast your vote for (number) members for the above seat(s) on the Council.
Choose (number) candidates only.

REPRESENTATIVE CANDIDATES
[

]

[

]

[

]

PLEASE BE SURE TO COMPLETE THE FOLLOWING CERTIFICATION STATEMENT:
I certify that I have produced a minimum of 20,000 pounds of processed raspberries at the location
listed below during the twelve-month period of Month XX, 20xx to Month XX, 20xx:
Signature: ____________________________________________________________
Print Name: ___________________________________________________________
Address: _____________________________________________________________
City: _______________________ State: ____________ Zip Code: ____________
Phone: ____________________________Submission of Ballot to [Council/USDA]
Once you have completed and signed this ballot please place this ballot in the enclosed, self-addressed
envelope and mail it to the [Council/USDA]. Incomplete ballots, unsigned ballots, or ballots received
after Month xx, 20xx, will not be counted.

(Continued on Back of Page)

RAS-BAL (Rev. 03/17) Destroy previous edition.

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.

RAS-BAL (Rev. 03/17) Destroy previous edition.