SC-125 (984) CA. Walnuts (Public Member) Member/Alternate Nomin

OMB No. 0581-0178

UNITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

SPECIALTY CROPS PROGRAM

CONFIDENTIAL CALIFORNIA WALNUT BOARD NOMINEE QUESTIONNAIRE

PUBLIC MEMBER/ALTERNATE

The following information is needed and used by the Secretary of Agriculture to determine the eligibility and willingness of nominees to serve on the California Walnut Board (Board) under Federal Marketing Order No. 984. Failure to provide this information may hinder your selection by the Secretary.

1. Name:

2. (a) Residence:

(Street, City, State, and Zip Code)

(b) Mailing Address: (if same, so state)

(Street, City, State, and Zip Code)

(c) Telephone Number: (H) __________________ (W) __________________ (C) __________________

(d) E-mail Address: _________________________________________________________________________

3. Occupation – Employer ______________________________________________________________________

4. Organizations to which you belong _____________________________________________________________

__________________________________________________________________________________________

5. Have you previously served on the California Walnut Board? □ Yes □ No; if yes, for how many years? _____

6. Are you a walnut grower? □ Yes □ No

7. Are you affiliated with a walnut handler (packer) as an employee, officer, director, or in any other capacity?

□ Yes □ No

8. When acting in my official capacity as a Board representative, I shall engage in only those activities that are authorized under the walnut marketing order. I also understand that the Board cannot become involved in lobbying and political activities.

9. I hereby certify that I am willing to serve as a member or alternate member on the California Walnut Board if selected by the Secretary of Agriculture.

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 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-125 (Rev. 1/2017) Destroy previous editions.