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

IF MORE SPACE IS NEEDED, USE ADDITIONAL FORMS. A COMPLETED BACKGROUND 

INFORMATION SHEET SIGNED BY EACH NOMINEE MUST BE ATTACHED. 

US. DEPARTMENT OF AGRICULTURE 

AGRICULTURAL MARKETING SERVICE 

. OMB NO. 0581-0093 

NOMINATION OF SOYBEAN PRODUCERS FOR APPOINTMENT TO THE UNITED SOYBEAN BOARD 

STATE/UNIT 

Pursuant to the Soybean Promotion, Research, and Consumer Information Act, the following names of soybean 

producers are submitted as nominees to the United Soybean Board (Board) as representatives of the indicated 

State. 

NAME(S) OF NOMINEE(S) 

(List name(s) for each allotted position on the Board) 

1. 

EMAIL ADDRESS (name@provider.com) 

NAME AND TITLE (PRINT OR TYPE) 

 

 

 

 

 

 

 

 

 

 

 

 

 

___________________________________________________________________________________________________________________________________________________ 

_____________________________________________________________________________________________________________________ 

NAME AND ADDRESS OF ORGANIZATION/ASSOCIATION 

TELEPHONE NO. (Include Area Code) SIGNATURE DATE 

Livestock and Poultry Program, AMS, USDA 

1400 Independence Avenue, SW.; Room 2625-S; STOP 0251 

Washington, D.C. 20250-0251 

RETURN FORMS TO: Research and Promotion Division 

LP-45R (Expiration Date 11/30/2024) See reverse for burden/non-discrimination statement 
 

 

 

 

 

 

 

 

 

 

 

 

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 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. 

LP-45R (Expiration Date 11/30/2024)