HWL-NOM Nomination for Appointment, Hardwood Lumber & Hardwood P

OMB No. 0581-NEW

NOMINATION FOR APPOINTMENT TO THE HARDWOOD LUMBER AND HARDWOOD PLYWOOD PROMOTION, RESEARCH AND INFORMATION BOARD

7 CFR PART 1211

The following statements are made in accordance with the Privacy Act of 1974 (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 (Hardwood Lumber Manufacturer or Hardwood Plywood Manufacturer and the District or Area) for which each person is nominated. Nominees must meet eligibility requirements as described in §§ 1211.41 and 1211.42 of the Order. Nominees must also manufacture and sell the majority of their hardwood lumber from the district for which they are nominated or for hardwood plywood in the area they are nominated (east or west of the Mississippi). The Districts are 1, 2, 3, 4 or 5 (see Order for the States in the respective Districts).

Print Nominees Name _______________________________________________ District/Area____________

Address:

Name of Organization/Person: _______________________________________ Tax ID/Bus.#________________

Address: ___________________________________________________________________________________

City: _________________________ State: ________________ Zip: __________________

Phone No. ______________________ Fax No. _____________________

E-Mail: ________________________

________________________________________________________________________________________________________

Signature of Nominee Date

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-NEW. 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.

The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance program (not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET Center at (202) 720-2600 (voice and TDD). To file a complaint of discrimination, write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

Signatures of at least 20 persons who pay or will pay assessments under the Order.

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Return Original Forms to: Hardwood Lumber and Hardwood Plywood Promotion,
Research and Information Board

Street,
City, State, Zip Code

HWL-NOM (06/12)