F/H Form F(2) 982) Hazelnut Ballot (Growers)

OMB No. 0581-0178

HAZELNUT MARKETING BOARD

21595-A Delores Way N.E.

Aurora, OR 97002-9738

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GROWER BALLOT

(To be submitted by eligible growers ONLY)

Please write in the name of one grower from your district who you would like to have represent growers from your district on the Hazelnut Marketing Board. This election is for a two year term beginning July 1, 20___.

DISTRICT NO. __________ CANDIDATE NAME ______________________________________________

This Ballot must be postmarked no later than April 30, 20___ to be valid. I hereby certify that I produced hazelnuts during the past season in the district noted above.

County in which orchard is located: ________________________________________________________________

_________________________________________ ___________________________________________

Print Name Signature

_____________________________________________________________________________________________

Address (include City, State, and Zip Code)

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 0581-0178. The time required to complete this information collection is estimated to average 3 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.

The following growers have been nominated to serve on the Hazelnut marketing Board (Board) from the districts noted. The person receiving the highest number voters in a district will be the member and the person receiving the second highest number of votes will become the alternate member. Growers may vote for only one candidate and are only eligible to vote only for a candidate in a district in which they produce hazelnuts. Any eligible grower can be elected to the Board. A grower need not be nominated and his/her name does not need to appear below for him/her to be eligible to serve. Write-in candidates are permissible. The Board encourages qualified women, minorities, and physically challenged candidates to participate and seek membership.

NOMINEES

DISTRICT NO. 1 (State of Washington, Clackamas, and Multnomah Counties)

1. _________________________

2. _________________________

DISTRICT NO. 2 (Marion and Polk Counties)

1. _________________________

2. _________________________

DISTRICT NO. 3 (Linn, Lane, and Benton Counties)

1. _________________________

2. _________________________

DISTRICT NO. 4 (Yamhill County)

1. _________________________

2. _________________________

DISTRICT NO. 5 (Washington and all other Counties)

1. _________________________

2. _________________________

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HAZELNUT MARKETING BOARD

21595-A Delores Way N.E.

Aurora, OR 97002-9738

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.

F/H Form F(2) (Rev. 01/2017) Destroy previous editions.