ABC-19 Almond Board of CA. - Independent Grower Petition

OMB No. 0581-0178

Almonds.com • 1150 Ninth St, Ste 1500 • Modesto, CA 95354 USA • T: +1.209.549.8262 • F:+1.209.549.8267

ALMOND BOARD OF CALIFORNIA

INDEPENDENT GROWER PETITION

NOMINEE’S NAME	PHONE NUMBER
NOMINEE’S ADDRESS
CITY	STATE ZIP
EMAIL ADDRESS
HANDLER

Check appropriate box for nominee:

□ Almond Board Member Position No. ________________

□ Alternate

For term of office beginning August 1, 20_____.

1) __________________________________________________________

(Name, please print)

__________________________________________________________

(Address)

__________________________________________________________

(City) (State, Zip)

__________________________________________________________

(Handler)

__________________________________________________________

(Signature)

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 OMB 0581-0178. The time required to complete this information collection is estimated to average 10 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.

ALMOND BOARD OF CALIFORNIA

INDEPENDENT GROWER PETITION (Cont.)

2) __________________________________________________________

(Name, please print)

__________________________________________________________

(Address)

__________________________________________________________

(City) (State, Zip)

__________________________________________________________

(Handler)

__________________________________________________________

(Signature)

3) __________________________________________________________

(Name, please print)

__________________________________________________________

(Address)

__________________________________________________________

(City) (State, Zip)

__________________________________________________________

(Handler)

__________________________________________________________

(Signature)

4) __________________________________________________________

(Name, please print)

__________________________________________________________

(Address)

__________________________________________________________

(City) (State, Zip)

__________________________________________________________

(Handler)

__________________________________________________________

(Signature)

ALMOND BOARD OF CALIFORNIA

INDEPENDENT GROWER PETITION (Cont.)

5) __________________________________________________________

(Name, please print)

__________________________________________________________

(Address)

__________________________________________________________

(City) (State, Zip)

__________________________________________________________

(Handler)

__________________________________________________________

(Signature)

6) __________________________________________________________

(Name, please print)

__________________________________________________________

(Address)

__________________________________________________________

(City) (State, Zip)

__________________________________________________________

(Handler)

__________________________________________________________

(Signature)

7) __________________________________________________________

(Name, please print)

__________________________________________________________

(Address)

__________________________________________________________

(City) (State, Zip)

__________________________________________________________

(Handler)

__________________________________________________________

(Signature)

ALMOND BOARD OF CALIFORNIA

INDEPENDENT GROWER PETITION (Cont.)

8) __________________________________________________________

(Name, please print)

__________________________________________________________

(Address)

__________________________________________________________

(City) (State, Zip)

__________________________________________________________

(Handler)

__________________________________________________________

(Signature)

9) __________________________________________________________

(Name, please print)

__________________________________________________________

(Address)

__________________________________________________________

(City) (State, Zip)

__________________________________________________________

(Handler)

__________________________________________________________

(Signature)

10) __________________________________________________________

(Name, please print)

__________________________________________________________

(Address)

__________________________________________________________

(City) (State, Zip)

__________________________________________________________

(Handler)

__________________________________________________________

(Signature)

ALMOND BOARD OF CALIFORNIA

INDEPENDENT GROWER PETITION (Cont.)

11) __________________________________________________________

(Name, please print)

__________________________________________________________

(Address)

__________________________________________________________

(City) (State, Zip)

__________________________________________________________

(Handler)

__________________________________________________________

(Signature)

12) __________________________________________________________

(Name, please print)

__________________________________________________________

(Address)

__________________________________________________________

(City) (State, Zip)

__________________________________________________________

(Handler)

__________________________________________________________

(Signature)

13) __________________________________________________________

(Name, please print)

__________________________________________________________

(Address)

__________________________________________________________

(City) (State, Zip)

__________________________________________________________

(Handler)

__________________________________________________________

(Signature)

ALMOND BOARD OF CALIFORNIA

INDEPENDENT GROWER PETITION (Cont.)

14) __________________________________________________________

(Name, please print)

__________________________________________________________

(Address)

__________________________________________________________

(City) (State, Zip)

__________________________________________________________

(Handler)

__________________________________________________________

(Signature)

15) __________________________________________________________

(Name, please print)

__________________________________________________________

(Address)

__________________________________________________________

(City) (State, Zip)

__________________________________________________________

(Handler)

__________________________________________________________

(Signature)

NOTE: Petition must be signed by at least 15 independent growers and received at the ABC office at 1150 9^th Street, Suite 1500, Modesto, California, 95354 by April 1, 20_____.

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.

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ABC-19 (Exp. x/xxxx) Destroy previous versions.