SC-166 (983) Prune Marketing Committee Public Nominee Questionn

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

UNITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

SPECIALTY CROPS 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.

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-166 (Rev. 01/2017) Destroy previous editions.