FV-139 Hazelnuts (Public Member) Background Questionnaire

OMB NO. 0581-0178

REPRODUCE LOCALLY. Include form number and date on all reproductions.

U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
FRUIT AND VEGETABLE PROGRAMS

HAZELNUT MARKETING BOARD
21595-A Dolores Way, N.E.
Aurora, OR 97002-9738

CONFIDENTIAL BACKGROUND STATEMENT
(PUBLIC MEMBER)
MARKETING ORDER NO. 982
COMMITTEE YEAR

POSITION
Name

Telephone<---J

Mailing Address (include city, county, State, and ZIP)

Occupation

Do you have a financial interest in a growing or handling operation of the commodity regulated under this marketing order?
Yes

No

If yes, explain

Membership in industry organizations

Marketing order committee members, in their official capacities, are prohibited ftom 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 ftom attempting to influence State or Federal government actions or policies or those offoreign
govenunents, except as specifically authorized under the marketing order or expressly approved by the Secretary. Committee members are specifically precluded ftom
authorizing the expenditure of marketing order funds for the purpose of attempting to influence legislation or govenunent actions. These same prohibitions apply to conunittee
managers, staB: and contractors, except that committee managers may consult with the Department of Agriculture (USDA) employees during the pendency of informal
rolemaking actions.
Ifmarketing order conunittee or subcommittee members or conunittee employees are sued individually or jointly for errors injudgement, 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 lustice (001). Alternatively, legal defense may be provided through private counsel, if recommended by USDA and
approved by 001. USDA and 001 enjoy an excellent working relationship with respect to providing legal representation for conunittee members and employees, either by
001 or through authorized private counsel. USDA is committed to a comprehensive legal defense policy for all conunittee members and employees acting within the scope of
their authorized conunittee duties and responsibilities.

I am willing to serve on the Hazelnut Marketing Board.

(Signature)

(Date)

The above Infonnation is required to detennine the eligibUltyand willingness of the nondnee to serve on the committee.
According to the Paperwork Reduction Act of 1995, an agency may not conduct or sponsor, and a per.;on is not required to respond to a collection of information unless it displays a valid OMB control
nwnber. The valid OMB control nwnber for this information collection is 0581-0118. The time required to complete this information collection is estimated to average 3 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. age, disability, and where applicable, sex, marital status, familial
status, parental status, religion, sexua1 orientation. genetic information. political beliefs, reprisal, or because all or part of an individual's income is derived fium 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) 120-2600 (voice and TDD). To file a complaint of discrimination. write to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW., Washington. D.C.
20250-9410, or call (800) 195-3212 (voice) or (202) 120-6382 (TDD). USDA is an equal opportunity provider and employer.

FV-139 (12106)