Form LS-87 Nomination of Sheep Industry Board

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FORM APPROVED- OMB NO. 0581-0263
U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

NOMINATIONS TO THE NATIONAL SHEEP INDUSTRY IMPROVEMENT CENTER BOARD

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unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0581-026. The time required to complete this
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and maintaining the data needed, and completing and reviewing the collection of information.
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where applicable, sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part
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1. STATE/UNIT

NAMES(S) OF NOMINEE(S)
(List name(s) for each allotted position on the Board)

IF MORE SPACE IS NEEDED, USE ADDITIONAL FORMS.
A COMPLETED BACKGROUND INFORMATION SHEET SIGNED BY EACH NOMINEE MUST BE ATTACHED.

2. IDENTIFICATION OF PERSON AND ORGANIZATION/ASSOCIATION SUBMITTING THESE NOMINATIONS
A. NAME AND ADDRESS OF ORGANIZATION/ASSOCIATION

C. NAME AND TITLE (PRINT OR TYPE)

D. E-MAIL ADDRESS (name@provider.com)

B. FACSIMILE NO. AND AREA CODE

E. SIGNATURE

RETURN FORMS TO: 5HVHDUFKDQG3URPRWLRQ'LYLVLRQ
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U.S. Department of Agriculture, Room 268-S
1400 Independence Avenue, SW, MAIL STOP 0251
Washington, DC 20250-0251
FAX: 202/720-1125
LS-87 (07-13)

DATE