SC-259 929-Cranberries Qualification Statement Public Member/Al

OMB No. 0581-0189

UNITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

SPECIALTY CROPS PROGRAM

QUALIFICATION STATEMENT

(CONFIDENTIAL)

Cranberry Marketing Committee – Public Member and Alternate

The following information will be used by the Secretary of Agriculture in selecting a Public Member representative to serve on the Cranberry Marketing Committee. The Cranberry Marketing Committee administers Federal Marketing Order No. 929, which regulates the handling of cranberries grown in Massachusetts, Rhode Island, Connecticut, New Jersey, Wisconsin, Michigan, Minnesota, Oregon, Washington, and Long Island in the State of New York.

Name:

Mailing Address:

Town/City: _____________________________________ State: _____ Zip Code: __________

Telephone: (H) ________________________________ (W) ___________________________________

Fax: ______________________________________ Email: ____________________________________

Educational Background:

Occupation: (Employer's Name & Address):

Briefly state your qualifications and why you are interested in serving as the public and alternate member on the Committee.

Briefly state your past and current work (service) with public groups. Please indicate offices held, etc.

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 0581-0189. 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.

Please list dates and give a brief summary of any other experience you believe would be pertinent. If a student, please state your major and minor course of study.

Please list the organizations to which you belong or are affiliated:

Do you or members of your immediate family have financial interest in or close association with the production, processing, financing, or marketing of agricultural commodities? Yes  No:

NOTE: The public member and alternate public member are not salaried positions. However, authorized travel expenses, while on Committee related business, are reimbursable.

I hereby certify that I am qualified to serve on the Cranberry Marketing Committee. If selected by the Secretary, United States Department of Agriculture, I will carry-out the duties of this position as defined in the Cranberry Marketing Order to the best of my ability.

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.

SC-259 (Rev. 9/2016. Destroy previous editions.)