OMB NO. 0581-0093

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 0581-0093. 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 maintain the data needed, and completing and review 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.

U.S. DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

NOMINATION OF PORK PRODUCERS OR IMPORTERS FOR APPOINTMENT

TO THE NATIONAL PORK PRODUCERS DELEGATE BODY

Pursuant to the Pork Promotion, Research, and Consumer Information Act of 1985 (Act), the following names of pork producers are submitted as nominees for 

appointment to the National Pork Producers Delegate Body as representatives of the State indicated. Nominations by individual producers or importers must be 

accompanied by a written petition as required by the Act.

1. STATE/UNIT

2. NAMES(S) OF NOMINEE(S) (List name(s) for each allotted position on the Delegate Body) 

IF MORE SPACE IS NEEDED, USE ADDITIONAL FORMS.

3. IDENTIFICATION OF PERSON AND ORGANIZATION/ASSOCIATION SUBMITTING THESE NOMINATIONS 

A. NAME AND ADDRESS OF ORGANIZATION/ASSOCIATION (or Name & 

Address of individual if NOT representing an organization) (Type or Print)

B. NAME AND TITLE OF ORGANIZATIONAL REPRESENTATIVE 

(Type or Print)

TELEPHONE NO. WITH AREA CODE FACSIMILE NO. AND AREA CODE

SIGNATURE (Organizational Representative or

Individual Submission)

DATE EMAIL ADDRESS (name@provider.com)

RETURN FORM AND BIOGRAPHICAL DATA FORMS (AD-755) TO:

National Pork Board

1776 Northwest 114th Street

Clive, Iowa 50325

LP-35 (Expiration Date 11/30/2024)