FV-61 Oregon/California Potatoes Background Questionnaire/Nomi

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

OMB No. 0581-0178

U.S. DEPARTMENT OF AGRICULTURE
AGRICULTURAL MARKETING SERVICE
FRUIT AND VEGETABLE PROGRAMS
CONFIDENTIAL BACKGROUND STATEMENT FOR COMMITTEE MEMBER
MARKETING ORDER NO. 947
DISTRICT ________________ POSITION __________________ _____ COMMITTEE YEAR _________
Name _________________________________________________
Telephone __________________________
Business Address ______________________________________________________________________________
(If you are a handler, also show your firm’s name and in what capacity you serve in such firm.)
E-mail address ________________________________________________________________________________
If Grower Member:

Years growing: _________
Potato acreage:____________________________

Handler Affiliation: ______________________________________________________________
If Handler Member:

Years handling:_________
Approximate truckloads handled: ________________
Membership in industry organizations: ___________________________________________________________
____________________________________________________________________________________________
Marketing order 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. Committee
members may not communicate with any official of a State or Federal legislative body for the purpose of attempting to
influence legislation. 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 order or
expressly approved by the Secretary. Committee members are specifically precluded from authorizing the expenditure of
marketing order funds for the purpose of attempting to influence legislation or government actions. These same
prohibitions apply to committee managers, staff, and contractors, except that committee managers may consult with the
Department of Agriculture (USDA) employees during the pendency of informal rulemaking actions.
If marketing order committee or subcommittee members or committee employees are sued individually or jointly for
errors in judgement, 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 agreement or order, they may be
authorized legal defense by the Department of Justice (DOJ). Alternatively, legal defense may be provided through
private counsel, if recommended by USDA and approved by DOJ. USDA and DOJ enjoy an excellent working
relationship with respect to providing legal representation for committee members and employees, either by DOJ or
through authorized private counsel. USDA is committed to a comprehensive legal defense policy for all committee
members and employees acting within the scope of their authorized committee duties and responsibilities.
I am willing to serve on the Oregon-California Potato Committee.
________________________________________________________
Signature

____________________________
Date

The above information is required to determine the eligibility and willingness of the nominee to serve on the
committee.
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 0581-0178. 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 to USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington, D.C. 202509410, or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

FV-61 (Rev 10/2010. Destroy previous editions.)