FV-109 Southeastern Committee Nominee Questionnaire

Form Approved

- OMB

No. 0581-0178

u.s. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
FRUIT AND VEGETABLE PROGRAMS

CONFIDENTIAL SOUTHEASTERN POTATO
COMMITTEE NOMINEE QUESTIONNAIRE
NOTE: Information to be used by the Secretary of Agriculture in selecting a producer or handler member or alternate member on the Southeastern
Potato Committee (Committee) under Federal Marketing Order No. 953 (Order). Statutory authority to obtain such information is provided in 7
U.S.C. 608. Failure to crovide this infolTnation mav hinder vour selection bv the Secretarv.

1.
2.

Name:_
Mailing Address:
Telephone: Home (
E-mail address:

(State)

(City)

(Street or P.O. Box)

Fax (

Business (

3.

If a producer. number of years you have been producing potatoes:

4.

Acres of potatoes you grew last season:

5.

If a handler. number of years handling potatoes:
Firm name:
Address:

6.

Ifyou have previously served on the Committee. what position did you hold?

7.

Membership and offices held in industry organizations:

_

(Zip Code)

years

Production in cwt:
Hundredweight handled last season:

_

Member

_

Alternate

8.

Have you ever been charged or convicted of any felony violations? (Generally, a felony is defined as
any violation of law punishable
by imprisonment
of longer than 1 year, except for violations
called misdemeanors
under State law which are punishable
by imprisonment
of 2
years or less.)
_Yes
_No.

9.

I hereby certify to the Southeastern Potato Committee and the Secretary of Agriculture that (a) I am
currently a producer of potatoes; and (b) I grew potatoes in the
crop year.

10.

I am aware that the producer and handler member and alternate positions are non-salaried. I am aware
that these positions may require travel. (Authorized travel expenses are reimbursable.)

11 .

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 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 expenditure of marketing order funds
for the purpose of attempting to influence legislation or government actions.
These same prohibitions apply to committee mangers. staff. and contractors. except that committee
managers may consult with the Department of Agriculture employees during the pendency of informal
rulemaking actions.

12.

If marketing order committee or subcommittee members or committee employees 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).

FV-109 (04104)

Alternatively. legal defense may be provided through private counsel. if recommended by the Department
of Agriculture (USDA)and approved by DOJ. USDAand 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.
I hereby accept the nomination as a producer or handler member or producer or handler alternate member of the
Southeastern Potato Committee. and will serve in such position if elected by my peers and selected by the Secretary of
Agriculture.

(Signature)

(Date)

(Please type or print name as given above)

N01E: 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 6 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.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, gender, religion, age, disability,
political beliefs, sexual orientation, and marital or family status. (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 TOO).

To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, St/I/, Washington,
20250-9410 or catl (202) 720-5964 (voice and TOO). USDA is an equal opportunity provider and employer.

FV-109

(05104)

D.C.