FV-125 CA. Walnuts (Public Member) Tenth Member/Alternate Nomin

OMB No. 0581-0178
UNITED STATES DEPARTMENT OF AGRICULTURE
Agricultural Marketing Service
Fruit and Vegetable Division
CONFIDENTIAL WALNUT MARKETING 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 Walnut Marketing
Board under Federal Marketing Order No. 984. Failure to provide this information may
hinder your selection by the Secretary.

(b)Your

Mailing

Address:

(if same,

so state)

3. Telephone

No:Home:

(state)

(city)

(street)

Cell:(

(

(zip)

Bus:L---L

4. Occupation - Employer
5. Organizations

to which you belong

6. Are you a walnut grower?

Yes

7. Are you affiliated with a walnut handler
director, or in any other capacity?

Yes

No
(packer) as an employee, officer,

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 Walnut Marketing Board if selected by the Secretary of Agriculture.

Date:

signature:

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searching existing dato sources, gathering and maintaining the data needed, and completing and reviewing the collection of information.
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origin, gender, religion, age, disability, sexual orientation, marital or family status, political beliefs, parental status, or protected genetic information.
(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 :sTARGET Center at (202) 720-2600 (voice and TDD).
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 14th andlndependenceAvenue,
Sw, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.
FV-125

(7/03) WALNUT

10m MEMBER QUESTIONNAIRE701