MUS-NBF Mushrooms Council Ballot

OMB No. 0581-0093

Mushroom Promotion, Research, and Consumer Information Order

Mail Ballot - Region #:

ELECTION OF NOMINEES TO SERVE ON THE MUSHROOM COUNCIL

Please read and complete all sections of this ballot. When voting, vote for ONLY one candidate by placing an "X" next to the Candidate's name. This ballot must be received not later than . All information on this ballot shall be kept strictly confidential in accordance with the requirements of 7 CFR Part 1209.62. Late or incomplete ballots will be invalid and will not be counted.

I. Ballot:

I Favor the Following Candidate to serve a 3-year term on the Mushroom Council: (Select one only).

( )

( )

( )

( ) (write in)

II. Certification:

I hereby CERTIFY that:

• During the period , through , I produced on average, ____________________ pounds of mushrooms for fresh use within the region. ^1,2

• During the period , through , I produced on average, ____________________ pounds of mushrooms for fresh use within the region. ^1,2

Therefore, during the period of ___________, through ____________, I produced on average
________________ pounds of mushrooms for fresh use within the region. ^1,2

Business Name Business address - Number and Street

(If individually owned, list name of sole proprietor.

If a partnership, corporation, association, or cooperative,

list name of business entity.) City, Town

Name of Individual Voting State Zip Code

_______________________________________ _______________________________________

Email Address (Area Code) Business Telephone Number

Signature of Individual Voting Title of Individual Voting

1/ The term "on average" shall be calculated by adding the voter's , through __ , production with the voter's ____, through , production and dividing by two. For example, if the voter’s _____ ,

through , production was 1 million pounds and the voter's , through , production was 2 million pounds. The

total for the period is 3 million pounds making the voter's "on average" production 1.5 million pounds.

2/ The making of any false statement or representation on this form, knowing it to be false, is a violation of Title 18, §1001 United States Code, which provides for the penalty of a fine of $10,000, imprisonment of not more than 5 years, or both.

OMB No. 0581-0093

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.

MUS-NBF (Expiration Date XX/XX/XXXX) See reverse for burden/non-discrimination statement