SWL-NOM Softwood Lumber--Nomination for Appt. to the Softwood Lu

OMB No. 0581-0093

NOMINATION FOR APPOINTMENT TO THE SOFTWOOD LUMBER BOARD
SOFTWOOD LUMBER RESEARCH, PROMOTION, CONSUMER EDUCATION AND INDUSTRY
INFORMATION ORDER
(7 CFR PART 1217)
The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 552a) and the Paperwork Reduction Act of 1995. The
authority for requesting this information to be supplied on this form is the Commodity Promotion, Research, and Information Act of 1996, Pub. L.
104-127, 110 Stat. 1032 (7 U.S.C. 7411-7425). Furnishing the requested information is necessary for the administration of this program. Submission
of the Tax Identification Number is mandatory, and will be used to determine affiliation or entity identification.

Names of Nominees and Position (Domestic Manufacturer or Importer and the REGION) for which each
person is nominated. Nominees must meet eligibility requirements as described in §§ 1217.40 and 1217.41
of the Order. Nominees must also domestically ship or import softwood lumber from the region for which
they are nominated and may be asked to provide substantiating documentation to the Board. The regions
are as follows: US West, US South, Northeast and Lake States; Canadian West; Canadian East; all other
importing countries (please specify).
Nominee Name ________________________________________ Region_______________________
Address:

Name of Person submitting these nominations

Name: ____________________________________ Tax ID/Importer#________________
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

Softwood Lumber Board

Street, City, State, Zip Code

SWL-NOM (rev. 03/17) Destroy previous edition.

Note: The making of any false statement or representation on this form, knowing it to be false, is a violation of Title 18, Section
1001 United States Code, which provides for the penalty of a fine of $10,000 or imprisonment of not more than five years, or both.
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.

SWL-NOM (rev. 03/17) Destroy previous edition.