Peer reviewer Application & Qualification Form

AMS Grant Programs

Peer Reviewer Application Form 8-18-16.xls

Farmers Market Promotion Program (State)

OMB: 0581-0240

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Overview

Form
Lookup


Sheet 1: Form

Peer Reviewer Application and Qualification Form


Complete the information below to indicate your qualifications to review FMPP/LFPP proposals. The form must include a copy of your résumé with all employment and volunteer locations. Email completed form and résumé to [email protected] and indicate in the subject line if you are applying to be an LFPP or FMPP Reviewer. For more information about the grant programs, visit http://www.ams.usda.gov/services/grants.

Last Name:
First Name:
Email:
Phone:
Fax:
Street Address:
City:
State:
Zip Code:

Academic Background:
Highest Degree in Education:
Degree Area:
Profession/Rank:









Employer:
Employer Name:
Department:

Employer Type (mark as many as appropriate):

Federal Employee
Private Sector Employee
Nonprofit Employee

State Employee
Farmer/Producer/Rancher
Public Benefit Corp

Tribal Government
CSA Employee
Economic Develop. Corp

Local Government
Retired/Volunteer
1862 Land Grant U.

1890 Land Grant University
1994 Land Grant University
Public non-Land-Grant U

Private College/University
Private Research
USDA EPSCoR

Small/Mid-sized Institution
Hispanic Serving Institution
Other Minority Serving I.

Other (Please specify):

Percent of Appointment (Academia):
Appointment Percent



Research




Teaching




Extension/Outreach




Administration




Total 0




Demographic Information (Optional):
Gender:



Race:



Ethnicity:




Previous Federal Grant Application Review:


Conflict(s) of Interest:


Expertise (mark as many as appropriate):

Grant Writer
WIC
Aggregator

Financial/Budget
SFMNP
Distributor

Nutrition
EBT
Direct Marketing

Architecture/Engineering
CSA Operator
Agri-Tourism

Farmers Market
SNAP
Processor

Farmers Market Manager
Agricultural Cooperative
Food Banks

Educator/Academia
Roadside Stand Operator
Environmental

Technical Assistance Marketing
Technical Assistance Business Planning
Agricultural Production

Technical Assistance Other (please specify):

Other (please specify):

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- -0240. The time required to complete this information collection is estimated to average 15 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, age, disability, and where applicable sex, marital status, or familial status, parental status religion, sexual orientation, genetic information, political beliefs, 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 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.

Sheet 2: Lookup

Highest Degree Profession/Rank Race Ethnicity Gender
B.A. Assistant Professor American Indian or Alaska Native Hispanic or Latino M
B.S. Associate Professor Asian Not Hispanic or Latino F
M.A. Professor Black or African American

M.S. Federal Employee Native Hawaiian or Other Pacific Islander

Ph.D. Producer White

J.D. Industry


M.D. Other


Other



File Typeapplication/vnd.ms-excel
AuthorWang, Kenneth - AMS
Last Modified ByPish, Marylin - AMS
File Modified2016-08-19
File Created2014-05-07

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