Collecting Handler Registration Statement

OMB NO. 0581-0093

EGG RESEARCH AND PROMOTION ORDER
Collecting Handler Registration Statement
Required by Public Law 93-428, The Egg Research and Consumer Information Act (as Amended by Public Law 96-276).

FOR OFFICE USE ONLY
----------------------------------------IDENTIFICATION NUMBER

RETURN TO:

AMERICAN EGG BOARD
STREET ADDRESS
CITY, STATE ZIP
PHONE:

(XXX) XXX-XXXX

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BUSINESS NAME AND ADDRESS (City, State, and ZIP Code)

CORPORATION
PARTNERSHIP

OTHER: ___________________
-----------------------------------------------------------------------TELEPHONE NUMBER (Include Area Code)

NAME(S) OF INDIVUDUAL(S) RESPONSIBLE FOR FILING AND CERTIFICATION OF REPORTS WITH AMERICAN EGG BOARD

_________________________________________________
NAME

_________________________________________________
TITLE

_________________________________________________
NAME (If corporation, please list name of president)

_________________________________________________
TITLE

TYPE OF REPORTING PERIOD (Please check one):
IMPORTANT: Date you first handled eggs ________________

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1. CALENDAR MONTH ACCOUNTING PERIOD
2. FOUR-WEEK ACCOUNTING PERIOD (13 EQUAL 4-WEEK PERIODS PER YEAR)
(Give starting date of four-week accounting period _______________________) (Sunday)

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3. TWELVE ACCOUNTING PERIODS ANNUALLY ON FOUR-WEEK, FOUR-WEEK, FIVE-WEEK CYCLES.
(Give starting dates of first six periods:)
1. Four-weeks beginning __________________ (Sunday)
2. Four-weeks beginning __________________ (Sunday)
3. Five-weeks beginning __________________ (Sunday)
4. Four-weeks beginning __________________ (Sunday)
5. Four-weeks beginning __________________ (Sunday)
6. Five-weeks beginning __________________ (Sunday)
_________________________________________________________________________________________________
_________________________________________________________________________________________________
SIGNATURE

LSP (Rev. 04/17)

TITLE

DATE

See reverse for burden/non-discrimination

The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 522a) and the Paperwork Reduction Act of 1995, as
amended. The authority for requesting this information to be supplied on this form is the Commodity Promotion, Research, and Information Act
of 1996, Pub. L. 104-127, 110 Stat.1032 (7 U.S.C. 7411-7425). Furnishing the requested information is necessary for the administration of this
program. Submission of Tax Identification Number (TIN) or Employer Identification Number (EIN) is mandatory, and will be used to determine
affiliation or entity identification”.
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 05810093. The time required to complete this information collection is estimated to average 10 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.