PEC-ACO Application for certified Organizations

OMB No. 0581-NEW

APPLICATION FOR CERTIFICATION OF ORGANIZATION

PECAN PROMOTION, RESEARCH, AND INFORMATION ORDER

(7 CFR PART 1223)

The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 522a) and the Paperwork Reduction Act of 1995, as amended. The authority for requesting this information to be supplied on this form is from the applicable commodity legislation for research and promotion programs. Furnishing the requested information is necessary for the administration of this program. Submission of Tax Identification Number (TIN) or importer identification number is mandatory and will be used to determine affiliation or entity identity.

1. Name of Importer Organization: ___________________________________ Tax ID# _________________

Address: ________________________________________________________________________________

City: _________________________ State: ________________ Zip: __________________

Phone No. ____________________ Fax No. ____________________ E-Mail: ______________________

2. Total Members in most recent calendar year: _________________

3. What percent of your members are considered pecan importers ___________?

4. How long has your organization been in existence? _____________

5. Does your organization represent a substantial number of importers who import or market a substantial volume of pecans? If yes, describe.

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6. What percent of the total volume of pecans imported in the U.S. do your members represent? (pound percent of total) ________ pounds ________ percent of total imports

7. Would your organization be willing to publicize open seats for the APPB, if so, describe how? _______________________________________________________________________________________

8. List of Source(s) from which your organization operating funds are derived: ________________________

________________________________________________________________________________________

9. Describe purpose/function of the organization. Does the organization promote, research or provide information about pecans, if so, please describe: _______________________________________________

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CERTIFICATION AND SIGNATURE

I hereby certify that: (1) an interest of this organization is in the importation or marketing of pecans and (2) the information provided in response to the above items is true, complete, and correct to the best of my knowledge. The organization also agrees to take reasonable steps to publicize to non-members the availability of open Board positions and will consider nominating a non-member if he or she expresses an interest in serving on the Board. The Secretary of Agriculture may examine our books, documents, papers, records, files, and facilities to verify any of the information submitted and may procure such other information as may be required to determine this organization’s eligibility for certification.

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Print Name and Title of Person Completing this Application

___________________________________________________________________________________________________

Signature Date

(please use additional paper if needed) (see reverse for burden/non-discrimination statement)

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IMPORTANT NOTES

NOTE: Information is collected in order to determine eligibility of organizations to nominate importers to serve as members of the American Pecan Promotion Board. Application is voluntary and information is held confidential.

Organizations must apply for certification by the Secretary to be eligible to participate in the making of nomination of importers to serve as members of the Board as provided in the Pecan Promotion, Research, and Information Order. Information submitted in response to all items must be complete. Please type or print clearly. Send original only to:

Branch

Street, City, State, Zip Code

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-NEW. 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.

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.

PEC-ACO

Exp. Date xx/xx/xxxx