AVO-NIF Hass Avocado Nominee Information

OMB No. 0581-0093

20xx HAB Nominees

PRODUCER (IMPORTER) NOMINEE INFORMATION FORM

Nominee Name: _______________________________________________________________________

Grove (Company) Name: ________________________________________________________________

Grove (Company) City & State: ____________________________________________________________

Number of years in the avocado industry: ________

List up to three leadership positions held in the avocado industry:

______________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________

______________________________________________________________________________________

List up to three leadership positions held in other organizations:

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

The information in the box above will be included in the ballot to inform voters about your candidacy. No attachments will be included

I declare under penalty of perjury that the foregoing is complete, true, and correct information. I understand that the information in the box above will be reproduced and included with election information mailed to eligible voters.

SIGNATURE: _____________________________________________ DATE: _____________________

In order for this form to be included in the ballot, it must be emailed to the HAB office no later than Month, Day, 20xx, by x:00 p.m. PST to: xx@hassavocadoboard.com

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.

AVO-NIF (Expiration Date XX/XX/20XX) See reverse for burden/non-discrimination statement