Concrete Masonry Products Research, Education, and Promo

OMB Control No. 0605-0029

Expiration Date: XX/XX/XXXX

United States Department of Commerce

Under Secretary for Economic Affairs

Concrete Masonry Products Referendum

Voter Registration Form

Manufacturers of Concrete Masonry Products who desire to participate in the Concrete Masonry Products Referendum must complete and return this form. Your vote in the referendum will determine whether the Department of Commerce implements an order to establish a program of research, education and promotion for concrete masonry products. For additional information go to (www.doc.gov).

Company Name (include parent company name if owned by another): _______________________________________________________________________________

Your company will receive a ballot for each Employer Identification Number it has that represents a location that produces concrete masonry units. Report one EIN (and related information) below and any additional EINs (and related information) in an attachment to this form.

Employer Identification Number (EIN) ________________

Manufacturing Plant Address:

Street _________________________________________________________

State __________________________________________________________

Zip Code _______________________________________________________

Tel #: ( )

e-mail:_________________________________

The number of concrete masonry unit machine cavities in operation at this address: _________

□ See attached for additional information (check this box if you include additional information).

Please check this box if appropriate

□ I am a Manufacturer of Concrete Masonry Units (CMU) and have manufactured CMU within the last 180 days at each of the locations reported on this form. USDOC may request documentation to verify your eligibility.

__________________________________ ______________________________

Print Name of company representative Signature of company representative

_____________________________

Date

Fax this form to (301) 278-xxxx or return this form in the enclosed, postage-paid envelope.

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.

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 25 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.

Privacy Act Statement

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.