HON-NOM Honey-Nomination for Appointment to the Honey Packers &

OMB No. 0581-0093

NOMINATION FOR APPOINTMENT TO THE HONEY PACKERS AND IMPORTERS RESEARCH, PROMOTION, CONSUMER EDUCATION, AND INDUSTRY INFORMATION ORDER

(7 CFR PART 1212)

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 from the applicable commodity legislation for research and promotion programs. Furnishing the requested information is necessary for the administration of this program. Submission of Tax Identification Number (TIN) or importer identification number is mandatory and will be used to determine affiliation or entity identity.

1. Please mark an “X” in the appropriate block for which you are submitting nominations. (Mark only one box.
If you are submitting nominations for more than one group below, a separate form must be filled out for each group.)

[ ] Producers [ ] Importers [ ] First Handlers [ ] Marketing Cooperative

2. Names of Nominees and Position for which each person is nominated (List two names for each allotted position on the Board).

3. When nominations are the result of a caucus, list the organizations or associations participating in the caucus.

______________________________________________________________________________________________________

______________________________________________________________________________________________________

4. Name of Person or Organization submitting these nominations.

Name of Organization/Person: ____________________________________________ Tax ID/SS#____________

Address: _____________________________________________________________________________________

City: _________________________ State: ________________ Zip: __________________

Phone No. ______________________ Fax No. _____________________ Email: ________________________

This organization/person represents:

[ ] Producers [ ] Importers [ ] First Handlers [ ] Marketing Cooperatives

Print Name and Title of Person Completing this Nomination

________________________________________________________________________________________________________

Signature Date

Return Original Forms to: National Honey Board

XXXXX

XXXXX

OMB No. 0581-0093

NOTE: 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 30 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.

HON-NOM (Expiration Date XX/XX/20XX) See reverse for burden/non-discrimination statement