FV-139 Hazelnuts (Public Member) Background Questionnaire

REPRODUCE LOCALLY. Include form number and date on all reproductions. OMB NO. 0581-0178

HAZELNUT MARKETING BOARD U.S. DEPARTMENT OF AGRICULTURE

21595-A Dolores Way, N.E. AGRICULTURAL MARKETING SERVICE

Aurora, OR 97002-9738 FRUIT AND VEGETABLE PROGRAMS

CONFIDENTIAL BACKGROUND STATEMENT

(PUBLIC MEMBER)

MARKETING ORDER NO. 982

POSITION _________________________________ COMMITTEE YEAR ________________________

Name ________________________________________________ Telephone No. _______________________

Mailing Address (include City, State, and Zip Code)

Occupation

Do you have a financial interest in a growing or handling operation of the commodity regulated under this marketing order? Yes □ No □

If yes, explain

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 Hazelnut Marketing Board.

__________________________________________________ ______________________________________________________

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 3 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-139 (Rev. 10/2010) Destroy previous editions.