FV-311 Confidential Background Statement (Grower/Sheller Questi

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

UNITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

SPECIALTY CROPS PROGRAM

CONFIDENTIAL BACKGROUND STATEMENT

AMERICAN PECAN COUNCIL (M.O. 986)

The Secretary of Agriculture (Secretary) needs the following information to determine whether you are qualified under Marketing Order No. 986 to serve on the American Pecan Council (Council). Statutory authority to collect this information is provided in 7 U.S.C. 608. Failure to provide this information may hinder your selection by the Secretary.

TERM:	POSITION: □ Member □ Alternate
REGION: □ Eastern □ Central □Western	SERVED PREVIOUSLY: □YES □NO		CERTIFIED ORGANIC: □ Yes □ No
MEMBERSHIP: □ Grower □ Sheller □ Accumulator
Name (Please Print):		Telephone No. (Include Area Code):	Fax No. (Include Area code):
Business Address (Street, City, County, State and ZIP Code):
Email Address:
Years Growing Pecans (If Grower):		Last Season’s Crop: Acres ___________ Total Inshell Production ____________
Years Handling Pecans (If Sheller or Accumulator):		Approximate Volume Handled ( inshell):
Firm Name (If Sheller or Accumulator if other than a sole proprietorship)
Membership in Industry Organizations:
Offices held or any other particular activity in past few years connected with industry programs:

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 OMB 0581-NEW 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.

This information is voluntary and data will not be used to grant preferential treatment

What is your gender? Ethnicity: What is your race? (Mark all that apply)

___ Male ___ Hispanic or Latino ___ American Indian or Alaska Native

___ Female ___ Not Hispanic or Latino ___ Asian

___ Black or African American

Do you have a disability? _____ ___ Native Hawaiian / Other Pacific Islander

□ YES □ NO ___ White

If selected, I accept the appointment and agree to serve during the period for which I am appointed and until my successor has been selected and qualified. I also agree that I will carry out assigned duties in administering the terms and provisions of the marketing order to the best of my ability. When acting in my official capacity as a Council representative, I shall engage in only those activities that are authorized under the marketing order.

Council 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. Council members may not communicate with any official of a State or Federal legislative body for the purpose of attempting to influence legislation. Council 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. Council 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 Council managers, staff, and contractors, except that Council managers may consult with the Department of Agriculture (USDA) employees during the pendency of informal rulemaking actions.

If Council members or Council 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 Council members and employees, either by DOJ or through authorized private counsel. USDA is committed to comprehensive legal defense policy for all Council members and employees acting within the scope of their authorized Council duties and responsibilities.

(Signature) (Date)

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: [email protected]. USDA is an equal opportunity provider, employer, and lender.

FV-311 (11/2015) Page 2 of 2