Form FV-311 National Leafy Green Vegetable Board Background Informat

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

OMB No. 0581-NEW

UNITED STATES DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
FRUIT AND VEGETABLE PROGRAMS

NATIONAL LEAFY GREEN VEGETABLE BOARD BACKGROUND INFORMATION
This information is used to determine qualifications, suitability and availability for service on the National Leafy Green Vegetable Board (Board).

PLEASE PRINT CLEARLY OR TYPE
1. Name (First, Middle, Last)
2. Home Address (include ZIP Code)

4. Company/Business Name

3. Contact Information
Business:
Home:
Fax:
E-mail:
5. Occupation/Title

6. Company/Business Address (include ZIP Code)

7. Years in Occupation

8. Company/Business Affiliation(s) and Location(s)

9. Please check zone(s) of place of business.
Zone 1 – CA, HI
Zone 2 – AK, ID, MT, OR, WA, WY
Zone 3 – AZ, CO, NV, NM, UT
Zone 4 – IL, IA, MN, NE, ND, SD, WI
Zone 5 – AR, KS, LA, MO, OK, TX

Zone 6 – DE, District of Columbia, IN, KY, MD, MI, OH,
VA, WV
Zone 7 – AL, FL, GA, MS, NC, SC, TN
Zone 8 – CT, ME, MA, NH, NJ, NY, PA, RI, VT

10. How are you involved in the leafy green vegetable industry?
Producer
Handler
Importer
Retailer
Foodservice Operator
Public
Member
Alternate
Willing
to
serve
as
Member
or
Alternate
11. Position of Interest
To be Completed by Producers Only
12. Are you a producer of leafy green vegetables who supplies a signatory handler?
13. Are you a certified organic producer of leafy green vegetables who supplies a signatory handler?
14. What is your current leafy green vegetable acreage?
What is your total acreage?

Yes
Yes

No
No

15. Do you have annual total receipts of leafy green vegetables of $750,000 per year or less as a
producer? Receipts means “total income” (or in the case of sole proprietorship, “gross income”) plus
“cost of goods sold,” as these terms are defined and reported to the Internal Revenue Service (IRS).
The annual receipts should be averaged for the last three completed fiscal years.

Yes

No

16. Are you a diversified farm producing a variety of crops or animals, or both, on one farm, as
distinguished from specialization of a single commodity? Variety of crops means any crop in
addition to those included in the definition of leafy green vegetables.

Yes

No

Yes
Yes

No
No

To be Completed by Signatory Handlers Only
17. Are you a signatory handler?
18. Are you a certified organic signatory handler of leafy green vegetables?

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19. Do you have annual total receipts of leafy green vegetables of $7,000,000 per year or less as a
handler? Receipts means “total income” (or in the case of sole proprietorship, “gross income”) plus
“cost of goods sold,” as these terms are defined and reported to the IRS. The annual receipts should
be averaged for the last three completed fiscal years.

OMB No. 0581-NEW

Yes

No

Yes

No

To be Completed by Retailers, Foodservice Operators, and Public Only
20. Are you engaged in the production or handling of leafy green vegetables?
To be Completed by All Nominees
21. Are you a member of a producer cooperative, cooperative marketing association, cooperative bargaining association,
handler cooperative, shareholder in a corporation, limited liability corporation, trust, association, or any other organization
furthering the interest of leafy green vegetable producers or handlers?
Yes
No
If Yes, please state the name, the type or organization, and your position in any and all organizations in which you are
affiliated or a member.

22. List or attach a resume of any other affiliations and/or service as a community leader that would benefit you in your
role as a member of this Board.

23. List or attach a resume of 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.

24. List or attach a resume of your business experience.

25. List or attach a resume of your education and any specialized experience.

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

OMB No. 0581-NEW

26. Have you ever been convicted of a felony? (A felony is defined as any violation of law punishable by imprisonment
Yes
No If Yes, please explain on a separate sheet of paper.
of longer than one year).
27. 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 National Marketing Agreement Regulating
Leafy Green Vegetables, have any civil or criminal actions been initiated against you?
Yes
No If Yes, please
explain on a separate piece of paper.
28. Name as you would prefer it to appear on official correspondence.
By signing this form, I hereby state that all information provided by me on this form is true to the best of my
knowledge and I agree to serve, if appointed by the Secretary of Agriculture.
Signature
Date

Marketing program board members in their official capacities are prohibited from taking any action specifically designed to influence
legislation, including any attempt to influence public opinion concerning legislation. Board members may not communicate with any
official of a State or Federal legislative body for the purpose of attempting to influence legislation. Board members are also prohibited
from attempting to influence State or Federal government actions or policies or those of foreign governments, except as specifically
authorized under the marketing program or expressly approved by the Secretary of Agriculture. Board members are specifically
precluded from authorizing the expenditure of marketing program funds for the purpose of attempting to influence legislation or
government actions. These same prohibitions apply to board managers, staff, and contractors except that board managers may consult
with U.S. Department of Agriculture (USDA) employees during the pendency of informal rulemaking actions.
If marketing program board members 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 program, they may be authorized legal defense by the U.S. Department of Justice (DOJ). Alternatively, legal defense may
be provided through private counsel, if recommended by the USDA and approved by DOJ. USDA and DOJ enjoy an excellent
working relationship with respect to providing legal representation for board members and employees, either by DOJ or through
authorized private counsel. USDA is committed to a comprehensive legal defense policy of all board members and employees acting
within the scope of their authorized duties and responsibilities.
Marketing program board members are expected to maintain an appropriate level of conduct and professionalism at all board
meetings. Failure to do so may result in removal from office.

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-NEW. 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.

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