SWL-NOM Softwood Lumber--Nomination for Appt. to the Softwood Lu

OMB No. 0581-0093

NOMINATION FOR APPOINTMENT TO THE SOFTWOOD LUMBER BOARD

SOFTWOOD LUMBER RESEARCH, PROMOTION, CONSUMER EDUCATION, AND INDUSTRY INFORMATION ORDER

(7 CFR PART 1217)

The following statements are made in accordance with the Privacy Act of 1974 (5 U.S.C. §552a) and the Paperwork Reduction Act of 1995. The authority for requesting this information to be supplied on this form is the Commodity Promotion, Research, and Information Act of 1996, Pub. L. 104-127, 110 Stat. 1032 (7 U.S.C. §§7411-7425). Furnishing the requested information is necessary for the administration of this program. Submission of the Tax Identification Number is mandatory, and will be used to determine affiliation or entity identification.

Names of Nominees and Position (Domestic Manufacturer or Importer and the REGION) for which each person is nominated. Nominees must meet eligibility requirements as described in §1217.40 and §1217.41 of the Softwood Lumber Research, Promotion, Consumer Education, and Industry Information Order. Nominees must also domestically ship or import softwood lumber from the region for which they are nominated and may be asked to provide substantiating documentation to the Board. The regions are as follows: US West; US South; Northeast and Lake States; Canadian West; Canadian East; and all other importing countries (please specify).

Nominee Name ________________________________________ Region_______________________

Address: ___________________________________________________________________________

City: ___________________________ State: __________________ Zip: _______________________

Phone No.: _______________________________ Email: ___________________________________

Name of Person submitting these nominations

Name: _____________________________________________ Tax ID/Importer#: _________________________

Address: ___________________________________________________________________________________

City: ______________________________ State: ___________________________ Zip: __________________

Phone No.: _________________________________ Email: _________________________________________

_______________________________________

Print Name and Title of Person Completing this Nomination

_________________________________________________________ _______________________________________________

Signature Date

Return Original Forms to: Softwood Lumber Board

Street

City, State, Zip Code

Note: 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.

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.

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