RAS-NOM Raspberry--Nomination for Appt. to the Nat'l Rasperrry C

OMB No. 0581-0093

NOMINATION FOR APPOINTMENT TO THE NATIONAL PROCESSED RASPBERRY COUNCIL
PROCESSED RASPBERRY PROMOTION, RESEARCH, AND INFORMATION ORDER
(7 CFR PART 1208)

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.

Names of Nominees and Position (Domestic Producer, Importer, Foreign Producer or At-Large member)
for which each person is nominated. Nominees must meet eligibility requirements as described in
§§ 1208.40 and 1208.41 of the Order.

When nominations are the result of organizations or associations making a recommendation, list the organizations or
associations.

Name of Organization/Person: ____________________________________________ Tax ID________________
Address: _______________________________________________________________________________________
City: _________________________ State: ________________ Zip: __________________
Phone No. ______________________ Fax No. _____________________ E-Mail: ________________________

Print Name and Title of Person Completing this Nomination

________________________________________________________________________________________________________

Signature

Return Original Forms to:

Date

National Processed Raspberry Council
Address
City, State zip

RAS-NOM (Rev 03/17) Destroy previous edition.

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 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.
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.

RAS-NOM (Rev.03/17) Destroy previous edition.