FV-166 Prune Marketing Committee Public Nominee Questionnaire

REPRODUCE LOCALLY. Include form number and date on all reproductions. OMB No. 0581-0178

UNITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

FRUIT AND VEGETABLE PROGRAM

CONFIDENTIAL PRUNE MARKETING COMMITTEE PUBLIC NOMINEE QUESTIONNAIRE

The following information will be used by the Secretary of Agriculture in selecting a public member and alternate member on the Prune Marketing Committee (Committee) under Federal Marketing Order No. 993. Statutory authority to obtain this information is provided in 7 U.S.C. 608.

Name: ____________________________________________ Email Address: _____________________________

Address: ____________________________________________________________________________________

Street, City, State, and Zip Code

Mailing Address: ______________________________________________________________________________

(If same, so state) Street, City, State, and Zip Code

Telephone: H: ____________ W: _____________ C: _____________ Fax: _________________

Your occupation: ______________________________________________________________________________

Employer: _______________________________________________ Title: _______________________________

Consumer-oriented organizations to which you belong: ________________________________________________

Do you (or members of immediate family) have financial interest in, or close association with, the production, processing, financing or marketing of agricultural commodities? Yes □ No □ If the answer is yes, please indicate interest or association: _________________________________________________________________________

Are you a member of any marketing association, bargaining association, or any other organization furthering the interest of prune producers? If so, state name and your position, if any: ___________________________________

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

When acting in my official capacity as a Committee representative, I shall engage in only those activities that are authorized under the Prune Marketing Order. I also understand that the Committee cannot become involved in lobbying and political activities.

I hereby accept the nomination as a public member or alternate public member of the Committee, and will serve in such position if selected by the Secretary of Agriculture.

Signature: __________________________________________________ Date: ____________________________

(Please type or print name as signed above)

(If any part of this questionnaire does not apply, please indicate 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 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 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, 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-166 (Rev. 01/2014. Destroy previous editions.)