FV-312 Confidential Background Statement (Public)

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)

PUBLIC MEMBER/ALTERNATE

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.

Name (Please Print):	Telephone No. (Include Area Code):		Fax No. (Include Area code):
Mailing Address (Street, City, County, State and Zip Code):
Email Address:		State of Residency
Are you or any member of your immediate family directly associated with the pecan industry, financially or otherwise? □ YES □ NO
If you have an indirect relationship with the pecan industry, please explain.
Please list all public interest and service type organizations of which you are or have been a member, and list positions held with each organization.
Are you willing to familiarize yourself with the industry and the provisions of the Marketing Agreement and/or Order, with the understanding that members of the industry and the Council staff would assist you in this familiarization process? □ YES □ NO
Are you willing to spend the time necessary to represent the public properly on such Council? □ YES □ NO
List any special qualifications you may have which would enhance your qualifications to serve.

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

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 the USDA and approved by DOJ. The 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. The USDA is committed to a comprehensive legal defense policy for all Council members and employees acting within the scope of their authorized Council duties and responsibilities.

I certify that the information above is correct and I am willing to serve on the Council.

_____________________________________________ ________________________

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- 312 (11/2015) Page 2 of 2