FV-124 Confidential CWB Nominee Questionnaire

OMB No. 0581-0178

U.S. DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

FRUIT AND VEGETABLE PROGRAMS

CONFIDENTIAL CALIFORNIA WALNUT BOARD NOMINEE QUESTIONNAIRE

NOTE: This information will be used by the Secretary of Agriculture in selecting grower and handler members and alternates to serve on the California Walnut Board (Board) under Federal Marketing Order No. 984. Statutory authority to obtain this information is provided in 7 U.S.C. 608.

1. Name

2. (a) Residence:

(Street) (City) (State) (Zip)

(b) Mailing Address: (If same, so state)

(Street) (City) (State) (Zip)

(c) Telephone Number: Home (_____) Cell (_____)

Business (_____) E-mail address

3. Number of years of experience in the walnut industry

4. (a) Are you a producer of walnuts? ______ yes ______ no

(b) If 4(a) is “yes," state acreage of the English varieties of walnuts you own or lease: ___________ acres

5. (a) Did you produce walnuts during the current year? ______ yes ______ no

(b) If 5(a) is “yes,” state kernelweight pounds of the English varieties of walnuts you produced: ___________ pounds

6. If you are a walnut producer, employee, or officer of a walnut producer, state the name of your handler:

7. If you are a walnut handler, employee, or officer of a walnut handler, state the following:

(a) Name of the handler(s)

(b) Your title and capacity

(c) Number of years experience in the position

(d) Please state the kernelweight poundage of the English varieties of walnuts handled by your firm during the current crop year

pounds

8. When acting in my official capacity as a Board representative, I shall engage in only those activities that are authorized under the walnut marketing order. I also understand that the Board cannot become involved in lobbying and political activities.

9. If marketing order committee (or board) 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). Alternatively, legal defense may be provided through private counsel, if recommended by the Department of Agriculture (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.

10. I hereby certify that I am willing to serve as a member or alternate member on the California Walnut Board if selected by the Secretary of Agriculture.

(Please type or print name as signed) (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 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 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.

FV-124 (Rev. 04/09) Page 2 of 2