MUS-NFC Mushrooms Nomination

OMB No. 0581-0093

Nomination Form

My nomination(s) for candidate(s) in Region _____ are as follows:

1. Name_______________________________	2.Name_______________________________
Company____________________________	Company____________________________
Address_____________________________	Address_____________________________
City, State, Zip_______________________	City, State, Zip_______________________
Phone_______________________________	Phone_______________________________
3. Name_______________________________	4.Name_______________________________
Company____________________________	Company____________________________
Address_____________________________	Address_____________________________
City, State, Zip_______________________	City, State, Zip_______________________
Phone_______________________________	Phone_______________________________

I hereby certify that the company listed below produces over 500,000 pounds of mushrooms annually, on average, for fresh use.

Name:________________________________	Address:______________________________
Title:_________________________________	______________________________________
Company:_____________________________	Phone:________________________________
Signature:_____________________________	Date:_________________________________

See reverse for Burden Statement.

Return Completed form to: Mushroom Council

Street, City, State Zip

(xxx) xxx-xxxx (xxx) xxx-xxxx fax

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.

MUS-NFC (rev. 03/17) Destroy previous editions.