FV-97 915-Avocados Confidential Background Questionnaire/State

REPRODUCE LOCALLY. Include form number and date on all reproductions. OMB No. 0581-0189

UNITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

FRUIT AND VEGETABLE PROGRAM

CONFIDENTIAL BACKGROUND STATEMENT

(To be completed by grower and handler members and alternates)

The Secretary of Agriculture (Secretary) needs the following information to determine whether you are qualified under Marketing Order No. 915 to serve on the Avocado Administrative Committee (Committee). Statutory authority to collect the information is provided in 7 U.S.C. §§ 601-674. Failure to provide this information may hinder your selection by the Secretary.
POSITION (Please mark the appropriate box):
GROWER MEMBER	GROWER ALTERNATE	HANDLER MEMBER			HANDLER ALTERNATE MEMBER
DISTRICT NUMBER (Please mark appropriate box): □ 1 □ 2
NAME:				EMAIL ADDRESS:
BUSINESS ADDRESS: NOTE: If a handler, also show firm name and in what capacity you serve in such firm)
TELEPHONE NUMBER: (Include area code)				FAX NUMBER: (Include area code)
HAVE SERVED PREVIOUSLY AS (Mark an “X” in the appropriate box): □ AVOCADO COMMITTEE MEMBER □ AVOCADO COMMITTEE ALTERNATE MEMBER
YEARS GROWING OR HANDLING AVOCADOS: □ GROWER □ HANDLER (Mark the appropriate box)			5a. IS YOUR OPERATION CERTIFIED ORGANIC? □ Yes □ No
6a. AVOCADO PRODUCTION LAST SEASON (if grower):
6b. APPROXIMATE NUMBER OF 55-LB EQUIVALENT HANDLED LAST SEASON (if handler):
LIST MEMBERSHIPS IN INDUSTRY ORGANIZATIONS:
OFFICE(S) HELD OR ANY OTHER ACTIVITY IN THE PAST FEW YEARS CONNECTED WITH INDUSTRY PROGRAMS:
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 U.S. Department of Agriculture (USDA) employees during the pendency of informal rulemaking actions.
If 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 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.
COMMENTS:

CERTIFICATION STATEMENT: I certify that I meet the eligibility requirements of the Marketing Order and I am willing to serve on the Committee.

______________________________________________________ __________________________

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, gender, religion, age, disability, political beliefs, sexual orientation, and marital or family status. (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, Room 326-W, Whitten Building, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (202 &20-5964 (voice and TDD). USDA is an equal opportunity provider and employer.

FV-97 (Rev. 9/13. Destroy previous editions.) Page 2 of 2