AD-755 Advisory Committee or Research and Promotion Background

REPRODUCED LOCALLY: Include form number and date on all reproductions. Form – AD-755 Approved OMB No. 0505-0001

OMB Expiration Date: 5/31/2015

United States Department of Agriculture

ADVISORY COMMITTEE OR RESEARCH AND PROMOTION

BACKGROUND INFORMATION

[Insert the board/council name here]

Privacy Act Notice

Public Laws 95-113 and 93-579 permit collection of the data requested on this form. The information is used to determine qualifications, suitability and availability for service on advisory committees or research and promotion boards/councils. The information will be used to conduct background clearances and/or for annual reports on advisory committees or research and promotion boards/councils. Failure to submit this information may result in non-selection of a prospective advisory committee member, board/council member or termination of the committee or board/council.

PLEASE PRINT CLEARLY OR TYPE

1. Name (Last, First, Middle) – Mr., Mrs., Miss., Ms., Dr. 2. Social Security Number:

Passport Number(foreign citizens only):

Issuing Country (foreign citizens only):

Expiration Date (foreign citizens only):

3. Residence Address (include ZIP code) 4. Business No.

Home No:

Cell or Mobile:

FAX:

e-Mail Address:

5. Place of Birth 6. Date of Birth

7. This information is Voluntary and data will not be used to grant preferential treatment: (See last page for definition of categories.)

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

___ Native Hawaiian or Other Pacific Islander

___ White

8. Company/Business Name

9. Company/Business Address (include ZIP Code) 9a. Occupation/Title

10. [Insert appropriate commodity question(s) from supplemental list.] (To be completed by R&P Board Members Only)

10a. If applicable, how long have you been engaged in farming or production, and what is the size of your farming operation. (i.e.

List acreage and pounds produced by kind of crop, as well as, kinds and numbers of livestock?)

11. List your business experience. (Use the Continuation Sheet for additional space to answer.)

12. List education and any specialized experience. (Use the Continuation Sheet for additional space to answer.)

13. List applicable farm/handler/producer/importer or co-op member industry organizations (indicate whether a member or officer and how long affiliated).

14. List other affiliations and/or service as a community leader that would benefit you in your role as a member of the advisory committee or research and promotion board/council.

15. List any Federal advisory committee or board on which you are currently a member and the number of years you have served on that committee or board. (To be completed by current Advisory Committee Members Only)

16. List sources of income in excess of $10,000 for the past calendar year from other than your primary employment. List only sources; do not show amounts of income from each source. (To be completed by Advisory Committee Nominees Only)

_________________________________ _____________________________________

_________________________________ _____________________________________

17. Have you ever been convicted of a felony? (A felony is defined as any violation of law punishable by imprisonment of longer than one year). ( ) Yes ( ) No. If yes, please explain on the attached continuation sheet.

18. As a result of your participation in Federal programs, have any judgments been rendered against you? As a result of participation in any governmental programs relative to the purposes of the advisory committee or research and promotion board/council for which you are a nominee, have any civil or criminal actions been initiated against you?

( ) Yes ( ) No. If yes, please explain on the attached continuation sheet.

19. Name as you would prefer it to appear on official correspondence.

Signature Date

REPRODUCED LOCALLY: Include form number and date on all reproductions. Approved O.M.B. No. 0505-0001

OMB Expiration Date: 5/31/2015

Continuation Sheet for Form AD-755

If you need more space for an answer, use this sheet. Please number each answer to correspond to the number on Form AD-755. When you have completed your answer(s), attach to Form AD-755.

[INSERT COMMODITY BOARD, COUNCIL, OR DELEGATE NAME]

Name (Last, First, Middle)

Social Security or Passport Number:

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 0505-0001. The time required to complete this information collection is estimated to average 30 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.

Te 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) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.

Form – AD-755 Approved O.M.B. No. 0505-0001

OMB Expiration Date 5/31/2015

Definition of Ethnicity and Race Categories

Ethnicity:

A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Race:

American Indian or Alaska Native – A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American – A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White – A person having origins in any of the original peoples of Europe, the Middle East or North Africa.