SC-260 929-Cranberr Qualification Statement Grower or Grower Al

OMB No. 0581-0189

UNITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

SPECIALTY CROPS PROGRAM

QUALIFICATION STATEMENT

(CONFIDENTIAL)

Cranberry Marketing Committee –Members And Alternates

The following information will be used by the Secretary of Agriculture in selecting members or alternate members 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: ___________________________________

Number of years in cranberry business: _______________ Certified Organic: □ YES □ NO

During the last crop year, I produced __________ barrels of cranberries on ____________ acres in _______________________________ (county and name of nearest town), which I □ own or □ lease.

My cranberries are handled by the following handlers or marketing organization:

Other information: Positions or affiliations with industry groups, associations, etc.

If selected by the Secretary of Agriculture, will you serve as a (please specify) Member □ or Alternate Member □ on the Cranberry Marketing Committee? □ YES □ NO

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 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-260 (Rev. 9/2016. Destroy previous editions.)