HWL-BAL Ballot

Form Approved – OMB No. 0581-NEW

HARDWOOD LUMBER AND HARDWOOD PLYWOOD BOARD

HARDWOOD LUMBER AND HARDWOOD PLYWOOD PROMOTION,
RESEARCH AND INFORMATION ORDER

BALLOT

District/Area _____

The nominees listed on this ballot are seeking seat(s) on the Hardwood Lumber and Hardwood Plywood Promotion, Research and Information Board (Board). You are asked to cast your vote for (number) members for the above seat(s) on the Board. If you manufacture hardwood lumber or hardwood plywood from more than one district or area, you may only cast a ballot in one district or area of your choice.

Choose (number) candidates only.

REPRESENTATIVE CANDIDATES

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[ ]

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PLEASE BE SURE TO COMPLETE THE FOLLOWING CERTIFICATION STATEMENT:

I certify that I have manufactured and sold in annual sales of more than $2 million of covered hardwood lumber or have annual sales of more than $10 million of hardwood plywood during the twelve-month period of Month XX, 20xx to Month XX, 20xx:

Signature: ____________________________________________________________

Print Name: ___________________________________________________________

Company/Organization:__________________________________________________

Address: _____________________________________________________________

City: _______________________ State: ____________ Zip Code: ____________

Phone: ____________________________-

Submission of Ballot to Board

Once you have completed and signed this ballot please place this ballot in the enclosed, self-addressed envelope and mail it to the Board. Incomplete ballots, unsigned ballots, or ballots received after Month xx, 20xx, will not be counted.

(Continued on Back of Page)

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.

HWL-BAL (06/12)