FV-260 929-Cranberr Qualification Statement Grower or Grower Al

OMB No. 0581-0189

UNITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

FRUIT AND VEGETABLE PROGRAMS

QUALIFICATION STATEMENT

(CONFIDENTIAL)

Cranberry Marketing Committee –Members And Alternates

The following information will be used by the Secretary of Agriculture in selecting members or alternate members to serve on the Cranberry Marketing Committee. The Cranberry Marketing Committee administers Federal Marketing Order No. 929, which regulates the handling of cranberries grown in Massachusetts, Rhode Island, Connecticut, New Jersey, Wisconsin, Michigan, Minnesota, Oregon, Washington, and Long Island in the State of New York.

Name:

Mailing Address:

Town/City: _____________________________________ State: _____ Zip Code: __________

Telephone: (H) ________________________________ (W) ________________________________

Fax: ______________________________________ E-mail: ______________________________

Number of years in cranberry business:

During the last crop year, I produced __________ barrels of cranberries on ____________ acres in _______________________________________________ (county and name of nearest town), which I

□ own or □ lease.

My cranberries are handled by the following handlers or marketing organization:

Other information: Positions or affiliations with industry groups, associations, etc.

If selected by the Secretary of Agriculture, will you serve as a (please specify) Member □ or Alternate Member □ on the Cranberry Marketing Committee? □ YES □ NO

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 0581-0189. 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 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-260 (Rev. 7/10. Destroy previous editions.)