FV-285 CA. Date Administrative Committee Nominee Questionnaire

OMB No. 0581-0178

U.S. DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

FRUIT AND VEGETABLE PROGRAMS

CALIFORNIA DATE ADMINISTRATIVE COMMITTEE

CONFIDENTIAL NOMINEE QUESTIONNAIRE

The following information is used by the Secretary of Agriculture to determine the eligibility and willingness of nominees to serve on the California Date Administrative Committee (Committee). Please fill in all spaces and sign your name.

1. Name: ____________________________________________________________________________________

2. (a) Residential address: ______________________________________________________________________

Street City, State, Zip Code

(b) Mailing address: _________________________________________________________________________

If same, so state Street City, State, Zip Code

(c) Telephone No.: Home: _____________________________ Business: ____________________________

(d) Facsimile No.: __________________________________

3. No. of years in the date industry: _______

4. Bearing acreage of dates I own or lease: ______ acres. (“Dates” refer to Deglet Noor, Halawy, Khadrawy and Zahidi varieties only.)

5. Pounds of each of the following varietal types of dates I produced and had title to this past season:

Deglet Noor: __________________________________ Khadrawy: _______________________________

Halawy: ______________________________________ Zahidi: __________________________________

6. The handler(s) who handled my current date production is/are as follows:

Handler’s Name: _______________________________ Pounds: _____________________________

Handler’s Name: _______________________________ Pounds: _____________________________

7. If you are a date handler or employee or officer of a date handler, state:

1. The name of handler: _________________________________________________________________

2. Your title or capacity: ________________________________________________________________

8. If you are an employee or officer of a date producer, state:

1. Name of producer: ___________________________________________________________________

2. Your title or capacity: ________________________________________________________________

When acting in my official capacity as a Committee representative, I shall engage in only those activities that are authorized under the date marketing order. I also understand that the Committee cannot become involved in lobbying and political activities. I will serve as a member or alternate member on the Committee if selected by the Secretary of Agriculture.

Signature: _________________________________________________ Date: _______________________

If any part of this questionnaire does not apply, please indicate such by stating “N.A.” for non-applicable.

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 10 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 of 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, political beliefs, genetic information, 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, SW, Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer.

FV-285 (Rev. 10/2010) Destroy previous editions.