Form AD-755 Advisory Cmte or Research & Promotion Background Informa

REPRODUCED LOCALLY: Include form number and date on all reproductions. Form Approved O.M.B. No. 0505-0001

United States Department of Agriculture

ADVISORY COMMITTEE OR RESEARCH AND PROMOTION

BACKGROUND INFORMATION

U.S. Honey Producer Board

Privacy Act Notice

Public Laws 95-113 and 93-579 permit collection of the data requested on this form. The information is used to determine qualifications, suitability and availability for service on advisory committees or research and promotion boards/councils. The information will be used to conduct background clearances and/or for annual reports on advisory committees or research and promotion boards/councils. Failure to submit this information may result in non-selection of a prospective advisory committee member, board/council member or termination of the committee or board/council.

PLEASE PRINT CLEARLY OR TYPE

1 . Name (Last, First, Middle) 2. Social Security Number

3 . Residence Address (include ZIP code) 4. Business No.

Home No:

FAX:

e-Mail Address:

5. Place of Birth 6. Date of Birth

7. Company/Business Name

8. Company/Business Address (include ZIP Code) 9. Occupation/Title

10. How long have you been engaged in the production of honey (please specify)? ___________________

How many pounds of honey did you produce last year (please specify)? ___________________________

11. List your business experience.

1 2. List education and any specialized experience.

13. List applicable farm/handler/producer/importer or co-op member industry organizations (include whether a member or officer and how long affiliated).

14. List other affiliations and/or service as a community leader that would benefit you in your role as a member of the advisory committee or research and promotion board/council.

15. List any Federal advisory committee or board on which you are currently a member and the number of years you have served on that committee or board. (To be completed by Advisory Committees Only)

16. List sources of income in excess of $10,000 for the past calendar year from other than your primary employment. List only sources; do not show amounts of income from each source. (To be completed by Advisory Committees Only)

_________________________________ _____________________________________

_________________________________ _____________________________________

17. Have you ever been convicted of a felony? (A felony is defined as any violation of law punishable by imprisonment of longer than one year). ( ) Yes ( ) No. If yes, please explain on the attached continuation sheet.

18. As a result of your participation in Federal programs, have any judgments been rendered against you? As a result of participation in any governmental programs relative to the purposes of the advisory committee or research and promotion board/council for which you are a nominee, have any civil or criminal actions been initiated against you? ( ) Yes ( ) No. If yes, please explain on the attached continuation sheet.

19 Name as you would prefer it to appear on official correspondence. (To be completed by R&P Board Members Only)

Signature Date

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 0505-0001. The time required to complete this information collection is estimated to average 30 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, 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 to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

REPRODUCED LOCALLY: Include form number and date on all reproductions. Form Approved O.M.B. No. 0505-0001

Continuation Sheet for Form AD-755

If you need more space for an answer, use this sheet. Please number each answer to correspond to the number on Form AD-755. When you have completed your answer(s), attach to Form AD-755.

U.S. Honey Producer Board

_________________________________________________

N ame (Last, First, Middle)

S ocial Security Number:

AD-755 (10/02) – Revised (02/04)