SC-266-1 920-Kiwifruit (Public Member & Alternate) Confidential B

REPRODUCE LOCALLY. Include form number and date on all reproductions. OMB No. 0581-0189

U.S. DEPARTMENT OF AGRICULTURE AGRICULTURAL MARKETING SERVICE SPECIALTY CROPS PROGRAM CONFIDENTIAL KIWIFRUIT PUBLIC MEMBER NOMINEE QUESTIONNAIRE
The following information is required by the Secretary of Agriculture to determine the eligibility and willingness of nominees to serve on the Kiwifruit Administrative Committee.
INSTRUCTIONS: Please fill in all applicable spaces and sign your name.
1a. NAME
1b. BUSINESS NAME (If different from above)
2. MAILING ADDRESS (City, State, and ZIP)
3. TELEPHONE NUMBER (Include area code)	FAX NUMBER (Include area code)	EMAIL ADDRESS
4. HAVE YOU PREVIOUSLY SERVED ON THE KIWIFRUIT ADMINISTRATIVE COMMITTEE? ________ YES _________ NO IF YES, FOR HOW MANY YEARS DID YOU SERVE?
5. OTHER INFORMATION CONCERNING EXPERIENCE/ELIGIBILITY
6. Committee members, in their official capacities, are prohibited from taking any action specifically designed to influence legislation, including any attempt to influence public opinion concerning legislation. Committee members may not communicate with any official of a State or Federal legislative body for the purpose of attempting to influence legislation. Committee members are also prohibited from attempting to influence State or Federal government actions or policies or those of foreign governments, except as specifically authorized under the marketing order or expressly approved by the Secretary. Committee members are specifically precluded from authorizing the expenditures of marketing order funds for the purpose of attempting to influence legislation or government actions. These same prohibitions apply to committee managers, staff, and contractors except that committee managers may consult with U.S. Department of Agriculture employees during the pendency of informal rulemaking actions.
7. If Committee or subcommittee members or committee members are sued individually or jointly for errors in judgment, mistakes or other acts either of omission or commission (except for acts of dishonesty, willful misconduct, or gross negligence) in the conduct of their duties under the marketing agreement or order, they may be authorized legal defense by the Department of Justice (DOJ). Alternatively, legal defense may be provided through private counsel, if recommended by the Department of Agriculture (USDA) and approved by DOJ. USDA and DOJ enjoy an excellent working relationship with respect to providing legal representation for committee members and employees, either by DOJ or through authorized private counsel USDA is committed to a comprehensive legal defense policy for all committee members and employees acting within the scope of their authorized committee duties and responsibilities.
CERTIFICATION STATEMENT: I certify that I meet the eligibility requirements of the Order, that I am willing to serve on the Committee, that I currently have no financial involvement in the kiwifruit industry, and, while a public member, that I will undertake no financial interest in the production, processing, financing, buying, packing or marketing of kiwifruit. _______________________________________________________________________ ________________________________ Signature Date

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.

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 ttp://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-266-1 (Rev. 9/2016. Destroy previous editions.)