MAN-BAL Mangos Importer Nomination Ballot

OMB No. 0581-0093

NATIONAL MANGO BOARD (7 CFR 1206)

IMPORTER NOMINATION BALLOT

The nominees listed on this ballot are seeking a seat on the National Mango Board (NMB). As a mango importer, you are asked to vote for candidates in District (X). There are X positions available for District X. The individual receiving the highest vote totals will be considered the first choice of the industry for the vacant position and the next one will be considered the second choice for the position. Please mark your selections and completely fill in the information requested.

E-mail or fax this ballot for it to be received by NMB on or before XX, 20XX. Submissions received after this date will not be counted.

NATIONAL MANGO BOARD

Street

City, State, Zip Code

Email: xxxx

Telephone No. (XXX) XXX-XXXX

Please select XXX names from the list of nominees for District I:

XXXX  XXXX 

XXXX  XXXX 

Please select XXX names from the list of nominees for District II:

XXXX  XXXX 

XXXX  XXXX 

Please select XXX names from the list of nominees for District III:

XXXX  XXXX 

XXXX  XXXX 

Please select XXX name from the list of nominees for District IV:

XXXX  XXXX 

XXXX  XXXX 

Certification Statement

I certify that I imported 500,000 pounds or more of mangos at the location listed below during the 12-month period of January 1, 20XX, through December 31, 20XX.

(Please type or print)

Company/Business Name:________________________________________________________

Name:________________________________________________________________________

Title:__________________________________________________________________________

Address: ______________________________________________________________________

City: _______________________________ State: _______________ Zip code: ______________

Signature: __________________________________ Date: ___________________

OMB No. 0581-0093

DIVERSTIY STATEMENT

The National Mango Board (NMB) encourages industry members without regard to race, color, national origin, sex, religion, age, disability, political beliefs, sexual orientation, size of business/operation, and marital or family status or other basis protected by U.S. law to participate in NMB activities and seek a position on the NMB.

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.

MAN-BAL (Importer) (Expiration Date XX/XX/20XX) Page 1 of 2 See reverse for burden/non-discrimination statement