HON-NOM Honey-Nomination for Appointment to the Honey Packers &

OMB No. 0581-0093

NOMINATION FOR APPOINTMENT TO THE HONEY PACKERS AND IMPORTERS RESEARCH,
PROMOTION, CONSUMER EDUCATION AND INDUSTRY INFORMATION ORDER
(7 CFR PART 1212)
The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 522a) and the Paperwork Reduction Act of 1995, as
amended. The authority for requesting this information to be supplied on this form is from the applicable commodity legislation for research and
promotion programs. Furnishing the requested information is necessary for the administration of this program. Submission of Tax Identification
Number (TIN) or importer identification number is mandatory and will be used to determine affiliation or entity identity.

1. Please mark an “X” in the appropriate block for which you are submitting nominations. (Mark only one box.
If you are submitting nominations for more than one group below, a separate form must be filled out for each group.)
[ ] Producers

[ ] Importers

[ ] First Handlers

[ ] Importer/Handler

[ ] Marketing Cooperative

2. Names of Nominees and Position for which each person is nominated (List two names for each allotted position on the Board)

3. When nominations are the result of a caucus, list the organizations or associations participating in the caucus.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
4. Name of Person or Organization submitting these nominations

Name of Organization/Person: ____________________________________________ Tax ID/SS#________________
Address: _______________________________________________________________________________________
City: _________________________ State: ________________ Zip: __________________
Phone No. ______________________ Fax No. _____________________ E-Mail: ________________________
This organization/person represents: [ ] Producers
Cooperatives

[ ] Importers

[ ] First Handlers

[ ] Marketing

Print Name and Title of Person Completing this Nomination

________________________________________________________________________________________________________

Signature
Return Original Forms to:

HON-NOM (Rev. 03/17) Destroy previous editions.

Date
National Honey Board
Street Address
City, State, Zip Code

NOTE: 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 30
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: program.intake@usda.gov.
USDA is an equal opportunity provider, employer, and lender.

HON-NOM (Rev. 03/17) Destroy previous editions.