FV-266-1 920-Kiwifruit (Public Member & Alternate) Confidential B

REPRODUCE LOCALLY. Include form number and date on all reproductions.
U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
FRUIT AND VEGETABLE PROGRAMS

FORM APPROVED - OMB NO. 0581-0189

CONFIDENTIAL KIWIFRUIT PUBLIC MEMBER NOMINEE QUESTIONNAIRE
The following information is required by the Secretary of Agriculture to determine the eligibility and willingness of nominees to serve on
the Kiwifruit Administrative Committee.
INSTRUCTIONS: Please fill in all applicable spaces and sign your name.
1a.

NAME

1b.

BUSINESS NAME (If different from above)

2. MAILING ADDRESS (City, State, and ZIP)

3. TELEPHONE NUMBER (Include area code)

FAX NUMBER (Include area code)

4. NUMBER OF YEARS YOU HAVE BEEN A PRODUCER OF KIWIFRUIT

TRAYS OR TRAY EQUIVALENTS OF KIWIFRUIT FOR THE FRESH MARKET ON
5. DURING THE MOST RECENT SEASON,
PRODUCED. IF AN EMPLOYEE OF A GROWER, SPECIFY EMPLOYERS’S NAME:

ACRES WERE

6. NAME OF FIRM(S) WHICH HANDLED YOUR KIWIFRUIT DURING THE CURRENT SEASON

7. OTHER INFORMATION CONCERNING EXPERIENCE/ELIGIBILITY

8. Marketing order committee members, in their official capacities, are prohibited from taking any action specifically designed to influence legislation, including any attempt to influence public
opinion concerning legislation. Committee members may not communicate with any official of a State or Federal legislative body for the purpose of attempting to influence legislation.
Committee members are also prohibited from attempting to influence State or Federal government actions or policies or those of foreign governments, except as specifically authorized under
the marketing order or expressly approved by the Secretary.
Committee members are specifically precluded from authorizing the expenditures of marketing order funds for the purpose of attempting to influence legislation or government actions.
These same prohibitions apply to committee managers, staff, and contractors except that committee managers may consult with U.S. Department of Agriculture employees during the pendency
of informal rulemaking actions.

9. If marketing order committee or subcommittee members or committee members are sued individually or jointly for errors in judgment, mistakes or other acts either of omission or commission
(except for acts of dishonesty, willful misconduct, or gross negligence) in the conduct of their duties under the marketing agreement or order, they may be authorized legal defense by the
Department of Justice (DOJ). Alternatively, legal defense may be provided through private counsel, if recommended by the Department of Agriculture (USDA) and approved by DOJ. USDA
and DOJ enjoy an excellent working relationship with respect to providing legal representation for committee members and employees, either by DOJ or through authorized private counsel
USDA is committed to a comprehensive legal defense policy for all committee members and employees acting within the scope of their authorized committee duties and responsibilities.

CERTIFICATION STATEMENT:

(Signature)
NOTE:

I certify I meet the eligibility requirements of the Order and I am willing to serve on the
committee.

(Date)

The following statements are made in accordance with the Privacy Act of 1974 (U.S.C. 552a) and the Paperwork Reduction Act (PRA) of 1995. The authority for requesting this information to be supplied
on this form is the Agricultural Marketing Agreement Act of 1937, Sec. 1-19, 48 Stat. 31, as amended, (7 U.S.C. 601-674). Furnishing the requested information is necessary for the administration of
this program.

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 0581-0189. 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 source, gathering and maintaining the data needed, and completing and reviewing the collection of information.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, age, disability, and where applicable, sex, marital status,
familial status, parental status, religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance program ((Not
all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s
TARGET Center at 202-720-2600 (voice and TDD). To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, DC 20250-9410
or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

FV-266-1 (09/07)