FV-125 Confidential CWB Tenth Member/Alternate Nominee Question

OMB No. 0581-0178

UNITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

FRUIT AND VEGETABLE PROGRAMS

CONFIDENTIAL CALIFORNIA WALNUT BOARD

TENTH MEMBER/ALTERNATE NOMINEE QUESTIONNAIRE

The following information is needed and used by the Secretary of Agriculture to determine the eligibility and willingness of nominees to serve on the California Walnut Board under Federal Marketing Order No. 984. Failure to provide this information may hinder your selection by the Secretary.

Please fill in all spaces

1. Name

2. (a) Residence:

(street) (city) (state) (zip)

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

(street) (city) (state) (zip)

3. Telephone No: Home: (_____) Cell: (_____) Bus: (_____)

4. Occupation – Employer

5. Organizations to which you belong

6. Are you a walnut grower? ______ Yes ______ No

7. Are you affiliated with a walnut handler (packer) as an employee, officer, director, or in any other capacity?

______ Yes ______ No

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. 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.

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-125 (Rev. 04/09)