FV-41 Washington Potatoes Background Questionnaire/Nominee Que

OMB No. 0581-0178

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

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

STATE OF WASHINGTON POTATO COMMITTEE
P.O. Box 1815
Moses Lake, WA 98837

CONFIDENTIAL BACKGROUND STATEMENT
(COMMITTEE MEMBER)
MARKETING ORDER NO. 946
POSITION

DISTRICT
Name

COMMITTEE YEAR
Telephone Number

Business Address

(If you are a handler, also show your fInn's name and in what capacity you serve in such fmn.)

Years growing (if grower member)
Potato acreage (if grower member)
Years handling (if handler member)
Approximate cwt. handled (if handler member)
Membership in industry organizations

Marlcetingorder committee members, in their official capacities, are prohibited nom 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 nom attempting to influence State or Federal government actions or policies or those of foreign governments,
except as specifically authorized under the marlcetingorder or expressly approved by the Secretary. Committee members are specificaIly precluded ITomauthorizing the
expenditure of marlceting 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 consuh with the Department of Agricuhure (USDA) employees during the pendency of informal rulemaking actions.
Ifmarlceting order committee or subcommittee members or committee employees are sued individuaIly 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 marlcetingagreement 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 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.

I am willing to serve on the State of Washington Potato Committee.

(Signature)

(Date)

The above infonnation is required to detennine the eligibility and willingness of the nominee to serve on the committee.
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 coIlection ofinfonnation unless it
displays a valid OMB control number. The valid OMB control number for this infonnation coIlection is 0581-0178. 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 sources, gathering and maintaining the data needed, and
completing and reviewing the collection ofinfonnation.
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 infonnation, political beliefs, reprisal, or because all or part of an individual's
income is derived nom 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, audio tape, etc.) should contact USDA's TARGET Center at 202-720-2600 (voice and TOD). To file a complaint of
discrimination, write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call 800-795-3272 (voice) or (202) 720-6382
(TDD). USDA is an equal opportunity provider and employer.

FV-41 (1/07)