OMB No. 0581-0178

(Exp. 3/31/2024) Destroy previous editions.

CALIFORNIA DATE ADMINISTRATIVE COMMITTEE

P.O. Box 1736

Indio, CA 92202-1736

Tel: (760) 347-4510 Fax: (760) 347-6374

NOMINATION FOR MEMBERSHIP

I, _________________________________________________________________________________

representing _____________________________________________________________ (name of firm)

located at __________________________________________________________________________ ,

a Riverside County □ Producer □ Producer-Handler (check the appropriate category), nominate 

the following person(s) to serve as Producer or Producer-Handler representative(s) for the California Date 

Administrative Committee (Committee):

Name Mailing Address Phone Number

Signature: ____________________________________ Date: ___________________________

NOTE: Producers may only nominate Producer nominees. Producer-Handlers may only nominate 

Producer-Handler nominees.

Completed nomination forms must be received by the Committee no later than May ___, 20___ in order 

to be valid. They may be mailed or faxed to the Committee at the address above, or delivered to the 

Committee at USDA Service Center, 82-901 Bliss Avenue, Indio, CA.

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 0581-0178. The 

time required to complete this information collection is estimated to average 5 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.