PAP-NOM Paper-Nomination for Appointment

OMB No. 0581-0093

NOMINATION FOR APPOINTMENT TO THE PAPER AND PACKAGING BOARD

(Under the Commodity Promotion, Research, and Information Act of 1996, Pub. L. 104-127,110 Stat. 1032 (7 U.S.C. 7411-7425)
and the Paper and Paper-Based Packaging Promotion Research and Information Order, 7 C.F.R. 1222.1-1222.108)

The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 552a) and the Paperwork Reduction Act of 1995. The authority for
requesting the 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 the Tax Identification Number is
mandatory, and will be used to determine affiliation or entity identification.
The Paper and Paper-Based Packaging Order provides that manufacturers or importers of paper and paper-based packaging may nominate manufacturers or importers to
serve on the Paper and Packaging Board. Nominees must meet the eligibility requirements as described in §§ 1222.40 and 1222.41 of the Order. Nominated domestic
manufacturers must manufacture paper and paper-based packaging in the region (South, Northeast, Midwest or West) for which they are nominated. Nominees may be
nominated as a manufacturer or an importer, but not both. Domestic manufacturers may only be nominated in one region. At-Large Nominees shall manufacture at least
100,000 short tons but no more than 250,000 short tons of paper and paper-based packaging annually.
Attach a separate sheet ifadditional space is needed. Please submit a separate form for each nominee.
NAME, BUSINESS ADDRESS, AND TELEPHONE NUMBER OF NOMINEE

[ ] Regional Nominee:

[ ] SOUTH

[ ] WEST

[ ] MIDWEST [ ] NORTHEAST

[ ] Importer Nominee
Did the nominee manufacture or import 100,000 short tons
or more of paper and paper-based packaging? Y___ N___

[ ] At-large Nominee

(Must manufacture 100,000-250,000
short tons annually)

NAME AND MAILING ADDRESS OF PERSON OR ORGANIZATION SUBMITTING NOMINATION:

FILL OUT ATTACHED NOMINEE BACKGROUND FORM TO PROVIDE A SHORT SUMMARY OF THE NOMINEE’S EXPERIENCE IN THE PAPER AND PAPERBASED PACKAGING INDUSTRY AS WELL AS THE NOMINEE’S INVOLVEMENT IN ANY INDUSTRY ORGANIZATIONS.

Signature and Title of Person Completing this Nomination

___________________________________________________________________________________________________________________________
Signature
Date
Printed Name: ____________________________________________________

RETURN ORIGINAL TO:

Title: ________________________________________________

PAPER AND PACKAGING BOARD
Street
City, State Zip Code

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PAP-NOM (rev. 3/17) Destroy previous version.

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.

PAP-NOM (rev. 3/17) Destroy previous version.