PAP-BAL Paper- Nomination Ballot

OMB No. 0581-0093

PAPER & PACKAGING BOARD

PAPER AND PAPER-BASED PACKAGING PROMOTION, RESEARCH AND INFORMATION ORDER

(Region) BALLOT

The nominees listed on this ballot are seeking seat(s) on the Paper and Packaging Board (Board). You are asked to cast your vote for (number) members for the seat(s) on the Board.

Choose (number) candidates only.

(Region) REPRESENTATIVE CANDIDATES

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PLEASE BE SURE TO COMPLETE THE FOLLOWING CERTIFICATION STATEMENT:

I certify that, as an authorized representative of the company named below, the company has (domestically manufactured and/or imported) 100,000 short tons or more of paper and paper-based packaging during the twelve-month period of January 1, 20xx to December 31, 20xx:

Signature: ____________________________________________________________

Print Name: ___________________________________________________________

Company/Organization: __________________________________________________

Address: _____________________________________________________________

City: _______________________ State: ____________ Zip Code: ____________

Phone: ____________________________-

Submission of Ballot to Board

Once you have completed and signed this ballot please place this ballot in the enclosed, self-addressed envelope and mail it to: XXX, Address, City, State, zip code. Incomplete ballots, unsigned ballots, or ballots received after Month xx, 20xx, will not be counted.

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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-BAL (rev. 3/17) Destroy previous version.