LP-45-R Soybean Nomination Form

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US. DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE

NOMINATION OF SOYBEAN PRODUCERS FOR APPOINTMENT TO THE UNITED SOYBEAN BOARD

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Pursuant to the Soybean Promotion, Research, and Consumer Information Act, the following names of soybean producers are submitted as nominees to the United Soybean Board (Board) as representatives of the indicated State.

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1. STATE/UNIT

NAME(S) OF NOMINEE(S)

(List name(s) for each allotted position on the Board)

IF MORE SPACE IS NEEDED, USE ADDITIONAL FORMS. A COMPLETED BACKGROUND INFORMATION SHEET SIGNED BY EACH NOMINEE MUST BE ATTACHED.

3. IDENTIFICATION OF PERSON AND ORGANIZATION/ASSOCIATION SUBMITTING THESE NOMINATIONS

NAME AND ADDRESS OF ORGANIZATION/ASSOCIATION	NAME AND TITLE (PRINT OR TYPE)
	EMAIL ADDRESS (name@provider.com)
TELEPHONE NO. (Include Area Code)	SIGNATURE	DATE

RETURN FORMS TO: Research and Promotion Division

Livestock and Poultry Program, AMS, USDA FAX - (202) 720-1125

Street

City, State, and Zip

LP-45R (Expiration Date XX/XX/XXXX) See reverse for burden/non-discrimination statement

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

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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.

LP-45R (Expiration Date XX/XX/XXXX)