FV-313 Technical Review Cmte./Research & Development Cmte. Back

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OMB No. 0581-NEW

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

NATIONAL LEAFY GREEN VEGETABLE TECHNICAL REVIEW COMMITTEE/
RESEARCH AND DEVELOPMENT COMMITTEE BACKGROUND INFORMATION
This information is used to determine the qualifications, suitability and availability for service on the
Technical Review Committee or the Research and Development Committee.

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 Name(s) and Location(s)

To be Completed by Technical Review Committee Nominees Only
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

10.
11.
12.
13.

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

Are you a producer of leafy green vegetables who supplies a signatory handler?
Are you a certified organic producer of leafy green vegetables who supplies a signatory handler?
What is your current leafy green vegetable acreage?
What is your total acreage?
Are you a signatory handler?

14. Do you have annual total receipts of leafy green vegetables of $750,000 per year or less as a
producer or $7,000,000 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 Internal Revenue Service (IRS). The annual receipts should be averaged for the last three
completed fiscal years.
15. Do you have professional expertise related to food safety technology and science as it relates to
the production, handling, or manufacturing of leafy green vegetables in the respective zone?
To be Completed by Research and Development Committee Nominees Only
16. Are you a representative of a retailer?
17. Are you a representative of a foodservice operator?
18. Are you a public representative?

FV-313 (Rev. 3/2011)

Yes
Yes

No
No

Yes

No

Yes

No

Yes

No

Yes
Yes
Yes

No
No
No

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19. Are you a representative from a land grant university with expertise in fresh and fresh-cut
vegetable industry (for example, but not limited to: production, handling, marketing, of fresh and
fresh-cut leafy green vegetables; small diversified, or organic production and handling practices for
fresh and fresh-cut produce; agricultural economics; produce food safety; or, educational outreach in
the abovementioned areas.?
To be Completed by All Nominees
20. Are you engaged in the production or handling of leafy green vegetables?

OMB No. 0581-NEW

Yes

No

Yes

No

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 committee.

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.

FV-313 (Rev. 3/2011)

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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 piece 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 Regulation
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/committee 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/committee members may not
communicate with any official of a State or Federal legislative body for the purpose of attempting to influence legislation.
Board/committee 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/committee 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/committee
managers, staff, and contractors except that board/committee managers may consult with U.S. Department of Agriculture (USDA)
employees during the pendency of informal rulemaking actions.
If marketing program board/committee or subcommittee 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/committee members and
employees, either by DOJ or through authorized private counsel. USDA is committed to a comprehensive legal defense policy of all
board/committee members and employees acting within the scope of their authorized duties and responsibilities.
Marketing program board/committee members are expected to maintain an appropriate level of conduct and professionalism at all
board/committee 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.

FV-313 (Rev. 3/2011)

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