Concrete Masonry Products Research, Education, and Promotion Board Member Application Form

OMB Control No. 0605-XNEW

Expiration Date: XX/XX/XXXX

United States Department of Commerce

Under Secretary for Economic Affairs

Concrete Masonry Products Board

Member Application Form

Manufacturers of Concrete Masonry Products who desire to be considered for an appointment as a Board member or alternate Board member for the Concrete Masonry Products Board must complete and return this form. In addition to the below, you may also include any information you would like the Secretary to consider.

Applicant Name: _______________________________________________

Company Name: _______________________________________________

Manufacturing Plant Address:

Street _________________________________________________________

State __________________________________________________________

Zip Code _______________________________________________________

Telephone Number ( ) _______________________________________

E-mail: ________________________________________________________

Statement of desire (short paragraph why you would like the Secretary to consider you for Board membership, you may append additional information to this form):

Employer Identification Number(s) (EIN) ________________

Company size (number of employees): __________

Concrete masonry products types produced, - check all that apply and add those not on the list:

Product	Type	Check
Concrete masonry units	Concrete Block - Gray
	Concrete Block – Architectural
	Concrete Block – Prefaced
	Concrete Block - joined
	Concrete Block - Sound wall block
	Concrete Block - Fence block
	Concrete Block - Lintel Block
	Concrete Block - Screen Block
	Concrete Block - Chimney, Pilaster, or Column Block
	Concrete Block – other (denote type)
	Concrete Block – other (denote type)
	Concrete Block – other (denote type)
	Concrete Brick (Architectural only)
	Concrete Masonry Veneer Units (greater than 3 inches in width).
Non-unit products	Concrete pavers
	Segmental retaining wall
	Concrete Brick (non-Architectural)
	Concrete veneer (less than 3 inches in width)
	Other, non-unit products (please name types below)

Please check these boxes if appropriate:

□ I am a Manufacturer of Concrete Masonry Products (CMP) and have manufactured CMP within the last 180 days.

USDOC may request documentation to verify your eligibility

□ I desire consideration to be appointed as a member or alternate member on the Concrete Masonry Products Board.

__________________________________ ______________________________

Print Name of applicant Signature of applicant

_____________________________

Date

All information collected will be treated as confidential, as indicated on the forms and in conformance with the Privacy Act and Freedom of Information Act. The Department’s staff is required to maintain confidentiality. Other confidential information will be withheld from public review under the Freedom of Information Act and the Privacy Act, 5 USC 552.

Paperwork Reduction Act Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a currently valid OMB Control Number. This is a new collection and the valid OMB Control Number will be assigned when it is approved. The time required to complete this information 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. All responses to this collection of information are voluntary. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to the Department of Commerce, Office of the Under Secretary for Economic Affairs at 1401 Constitution Avenue, Washington, D.C. 20230, Attn: Kenneth White, Senior Policy Analyst, or kwhite2@doc.gov.