1 AEB Eggs Nomination Selections

OMB NO. 0581-0093

NOMINATION FORM

AMERICAN EGG BOARD — 20XX-20XX TERM

AREA XX

Nomination for Member and Alternate: List first and second choice for member and alternate. Four separate names must be listed for the nomination schedule to be accepted.

Member

1^st choice _____________________________ _____________________

Name Daytime Phone

_____________________________

City & State

2^nd choice _____________________________ _____________________

Name Daytime Phone

_____________________________

City & State

Alternate

1^st choice _____________________________ _____________________

Name Daytime Phone

_____________________________

City & State

2^nd choice _____________________________ _____________________

Name Daytime Phone

_____________________________

City & State

Caucus Leader for next year (20XX): ________________________________ ________________________________

(Name) (Organization)

AEB-1 (Expiration Date XX/XX/XXXX) See reverse for burden/non-discrimination statement

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 maintain the data needed, and completing and review 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.