LPS-35 Pork Producers or Importers Nomination Appointment to De

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FORM APPROVED - OMB NO. 0581-0093

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employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex,
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U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE

NOMINATION OF PORK PRODUCERS OR IMPORTERS FOR APPOINTMENT
TO THE NATIONAL PORK PRODUCERS DELEGATE BODY
Pursuant to the Pork Promotion, Research, and Consumer Information Act of 1985 (Act), the following names of pork producers are submitted as nominees for
appointment to the National Pork Producers Delegate Body as representatives of the State indicated. Nominations by individual producers or importers must be
accompanied by a written petition as required by the Act.

1. STATE/UNIT
2. NAMES(S) OF NOMINEE(S)

(List name(s) for each allotted position on the Delegate Body)

IF MORE SPACE IS NEEDED, USE ADDITIONAL FORMS.
3. IDENTIFICATION OF PERSON AND ORGANIZATION/ASSOCIATION SUBMITTING THESE NOMINATIONS
A. NAME AND ADDRESS OF ORGANIZATION/ASSOCIATION (or Name &
Address of individual if NOT representing an organization) (Type or Print)

B. NAME AND TITLE OF ORGANIZATIONAL REPRESENTATIVE
(Type or Print)

TELEPHONE NO. AND AREA CODE

SIGNATURE (Organizational Representative or
Individual Submission)

DATE

EMAIL ADDRESS (name@provider.com)

RETURN FORM AND BIOGRAPHICAL DATA FORMS (AD-755) TO:
National Pork Board
Street or P.O. Box
City, State Zip
LPS-35 (rev. 04/17)

FACSIMILE NO. AND AREA CODE