FV-109 Southeastern Committee Nominee Questionnaire

REPRODUCE LOCALLY. Include form number and date on all reproductions. OMB No. 0518-0178

U.S. DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

FRUIT AND VEGETABLE PROGRAMS

CONFIDENTIAL SOUTHEASTERN POTATO

COMMITTEE NOMINEE QUESTIONNAIRE

NOTE: This information is to be used by the Secretary of Agriculture (Secretary) in selecting a producer or handler member or alternate member on the Southeastern Potato Committee (Committee) under Federal Marketing Order No. 953 (Order). Statutory authority to obtain such information is provided in 7 U.S.C. 608. Failure to provide this information may hinder your selection by the Secretary.

1. Name: ________________________________________________________________________

2. Mailing Address: ________________________________________________________________

______________________________________________________________________________

Telephone: ________________ Fax ______________ E-mail: __________________________

3. If a producer, number of years you have been producing potatoes: _______years

4. Acres of potatoes you grew last season: ________ Production in cwt: _________________

5. If a handler, number of years handling potatoes: ____________

Hundredweight handled last season: ________________

Firm name: ____________________________________________________________________

Address: ______________________________________________________________________

______________________________________________________________________________

6. If you have previously served on the Committee, what position did you hold?

□ Member □ Alternate

7. Membership and offices held in industry organizations:

______________________________________________________________________________

______________________________________________________________________________

8. Have you ever been charged or convicted of any felony violations? (A felony is defined as any violation of law punishable by imprisonment of longer than 1 year, except for violations called misdemeanors under State law which are punishable by imprisonment of 2 years or less.)

□ Yes □ No

9. I hereby certify to the Committee and the Secretary that (a) I am currently a producer of potatoes; and (b) I produced potatoes during the 20___ crop year.

10. I am aware that the producer and handler member and alternate positions are non-salaried. I am aware that these positions may require travel. (Authorized travel expenses are reimbursable.)

11. 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 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 mangers, staff, and contractors, except that Committee managers may consult with the Department of Agriculture employees during the pendency of informal rulemaking actions.

12. If marketing order Committee or subcommittee members or Committee employees 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 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 the Department of Agriculture (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 hereby accept the nomination as a producer or handler member or producer or handler alternate member of the Southeastern Potato Committee, and will serve in such position if elected by my peers and selected by the Secretary of Agriculture.

__________________________________________ __________________________

Signature Date

__________________________________________

Print Name

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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-109 (Rev. 10/2010. Destroy previous editions.)