FV-285 CA. Date Administrative Committee Nominee Questionnaire

OMB No. 0581-0178

REPRODUCE LOCALLY. Include form number and date on all reproductions.

United States Department of Agriculture
Agriculture Marketing Service
Fruit and Vegetable Programs
CONFIDENTIAL CALIFORNIA DATE ADMINISTRATIVE COMMITTEE NOMINEE QUESTIONNAIRE
The following information will be used by the Secretary of Agriculture to determine the eligibility and willingness of nominees to
serve on California Date Administrative Committee: (Please fillin all spaces.)

1.
2.

E-mail address:

Name:.
(a) Residence:
(Street)
(b) MailingAddress:
(Ifsame, so state)
(c) Telephone Number: Home (
(d) Cell Number: ( )

(City)
(Street)

(State)
(City)

(State)

(ZipCode)
(ZipCode)

Business:

)

Facsimile Number:

L-J

3.

Number of years experience in the Date Industry:

4.

Bearing acreage of dates 1 I own or lease is

5.

Insert poundage of each of the following varietal types of dates I produced and had title to this past season:
Deglet Noor
Khadrawy
Halawy
Zahidi

6.

The handler(s) who handled my current date production is/are as follows:
Handler's Name
Pounds
Handler's Name
Pounds

7.

If you are a date handler or employee or officer of a date handler, state:
(1)
The name of handler:
(2)
Your title or capacity:

8.

If you are an employee or officer of a date producer, state:
(3)
The name of producer:
(4)

acres.

Your title or capacity:

When acting in my official capacity as committee representative,I shall engage in only those activitiesthat are authorized under the
Date Marketing Order. I also understand that the committee cannot become involved in lobbying and political activities.
I hereby accept the nomination as a member or alternate member on the California Date Administrative Committee if selected by the Secretary
of Agriculture.
Signature:
1/

Date:

"Dates" refer to Deglet Noor, Halawy, Khadrawy, and Zahidi varieties only.
(If any part of this questionnaire does not apply, please indicate by stating IIN.A.IIfor non-applicable.)

According to the Paperwork Reduction Act or 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 10 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 or 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,Officeor CivilRights, 1400Independence Avenue,S.W., Washington, D.C.20250-9410,or call (800) 795-3272 (voice)or (202) 720-6382(TDD).USDAis an
equal opportunity provider and employer.

FV-285 (07/07)