SC-266-2 920-Kiwifruit Official Nomination Form

OMB No. 0581-0189

KIWIFRUIT ADMINISTRATIVE COMMITTEE

OFFICIAL NOMINATION FORM

DISTRICT ____

Listed below are the incumbent Kiwifruit Administrative Committee (Committee) members and alternates for this district:

Incumbent Member: Incumbent Alternate Member:

Incumbent Member: Incumbent Alternate Member:

Incumbent Member: Incumbent Alternate Member:

We ask that you be mindful of the U.S. Department of Agriculture’s policy regarding Equal Employment Opportunity and Civil Rights and consider eligible women, minorities, and persons with a disability for membership on the Committee. We also ask that you be mindful of the Department’s policy regarding outreach to new members and small business entities. If you would like to nominate a grower, or their employee, and are unsure if they qualify in your district, please call our office at (916) 441-0678. Nomination forms must be postmarked no later than ____________________, 20____.

PLEASE PRINT THE NAMES OF NOMINEES IN THE SPACES PROVIDED BELOW. TO BE ELIGIBLE TO SERVE ON THE COMMITTEE, A NOMINEE MUST CURRENTLY BE PRODUCING KIWIFRUIT FOR MARKET, OR BE AN EMPLOYEE OF A CURRENT PRODUCER. ALL QUALIFIED NOMINEES FOR EACH POSITION WILL APPEAR ON THE FORTHCOMING BALLOT TO BE MAILED TO ALL KIWIFRUIT GROWERS, RESPECTIVE OF DISTRICTS.

MEMBER NOMINEES:

NAME ________________________________________________________________

NAME ________________________________________________________________

NAME ________________________________________________________________

ALTERNATE MEMBER NOMINEES:

NAME ________________________________________________________________

NAME ________________________________________________________________

NAME ________________________________________________________________

Nominator's Comments: (use reverse side of form if more space is required)

_________________________________________________________________________________________________

_________________________________________________________________________________________________

NOMINATOR’S CERTIFICATION STATEMENT: I certify that I am currently a kiwifruit grower and that to the best of my knowledge, the above nominees are currently kiwifruit growers or employees of growers in this district.

Signature: ________________________________________________________________________________________

Name: ___________________________________________ Phone No.: ________________________________

Address: __________________________________________________________________________________________

PLEASE COMPLETE THE NOMINATION FORM AND RETURN IT IN THE ENCLOSED PRE-ADDRESSED ENVELOPE TO THE COMMITTEE. INCOMPLETE FORMS OR FORMS POSTMARKED LATER THAN____________, 20 . MAY BE INVALIDATED. PLEASE CALL THE COMMITTEE AT (916) 441-0678 IF YOU HAVE ANY QUESTIONS.

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 OMB 0581-0189. The time required to complete this information collection is estimated to average 10 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.

KIWIFRUIT ADMINISTRATIVE COMMITTEE

DISTRICT #____

CANDIDATE STATEMENTS

Candidate Name, Member Candidate

(Statement)

Candidate Name, Member Candidate

(Statement)

Candidate Name, Member Candidate

(Statement)

Candidate Name, Alternate Member Candidate

(Statement)

Candidate Name, Alternate Member Candidate

(Statement)

Candidate Name, Alternate Member Candidate

(Statement)

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.

SC-266-2 (Exp. X/XXXX) Destroy previous editions.