FV-166 Prune Marketing Committee Public Nominee Questionnaire

OMB No. 0581-0178

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

CONFIDENTIAL PRUNE MARKETING COMMITTEE PUBLIC NOMINEE QUESTIONNAIRE
The following information will be used by the Secretary of Agriculture in selecting a public member and alternate member on the Prune Marketing
Committee under Federal Marketing Order No. 993. Statutory authorityto obtain this information is provided in 7 U.S.C. 608.
1.
2.

Name:
(a) Residence:
(Street)

(City)

(State)

(Zip)

(b) Mailing Address:
(Ifsame, so state)

(Street)

(City)

(State)

(Zip)

(c) Telephone Number:

Home {

Business {

Cell {

Fax {

Email
3.

Your occupation:
Title

Employer
4.

Consumer oriented organizations to which you belong:

5.
Do you (or members of immediatefamily) have financial interest in, or close association with, the production, processing, financing or
No _'
If answer is yes, pleaseindicate interest or association.
marketing of agricultural commodities? Yes

_

6.
Are you a member or any marketing association, bargaining association, or any other organizationfurthering the interest of prune
producers? If so, state name and your position, if any.

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

When acting in my official capacity as a committee representative, I shall engage in only those activities that are authorized under the
Prune Marketing Order. Ialso understand that the committee cannot become involved in lobbying and political activities.
I hereby accept the nomination as a public member or alternate public member of the Prune Marketing Committee, and will serve in such position if
selected by the Secretary of Agriculture.
Date

Signature
(Please type or print name as signed above)

(Ifany part of this questionnaire does not apply, please indicate by stating "NA." for non-applicable.)
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 informationunless it displays
a validOMBcontrolnumber. ThevalidOMBcontrolnumberforthis information
collectionis 0581-0178. Thetimerequiredto completethis information
collectionis estimatedto
average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and
reviewingthe 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,
politicalbeliefs, sexual orientation, and marital or familystatus. (Not an 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) 72~2600 (voice and TDD).
To file a complaint of discrimination, write USDA, Director,Officeof CivilRights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, DC 202~
9410 or call (202) 720-5964 (voice and TDD). USDAis an equal opportunity provider and employer.

FV-166 (05/04)