SC-285 (987) CA. Date Administrative Committee Nominee Question

OMB No. 0581-0178

U.S. DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

SPECIALTY CROPS PROGRAM

CALIFORNIA DATE ADMINISTRATIVE COMMITTEE

CONFIDENTIAL NOMINEE QUESTIONNAIRE

The following information is used by the Secretary of Agriculture to determine the eligibility and willingness of nominees to serve on the California Date Administrative Committee (Committee). Please fill in all spaces and sign your name.

1. Name: ____________________________________________________________________________________

2. (a) Residential address: ______________________________________________________________________

Street City, State, Zip Code

(b) Mailing address: _________________________________________________________________________

If same, so state Street City, State, Zip Code

(c) Telephone No.: Home: _____________________________ Business: ____________________________

(d) Facsimile No.: _________________________ (e) Email Address: ________________________________

3. No. of years in the date industry: _______

4. Bearing acreage of dates I own or lease: ______ acres. (“Dates” refer to Deglet Noor, Halawy, Khadrawy and Zahidi varieties only.)

5. Pounds of each of the following varietal types of dates I produced and had title to this past season:

Deglet Noor: __________________________________ Khadrawy: _______________________________

Halawy: ______________________________________ Zahidi: __________________________________

6. The handler(s) who handled my current date production is/are as follows:

Handler’s Name: _______________________________ Pounds: _____________________________

Handler’s Name: _______________________________ Pounds: _____________________________

7. If you are a date handler or employee or officer of a date handler, state:

1. The name of handler: _________________________________________________________________

2. Your title or capacity: ________________________________________________________________

8. If you are an employee or officer of a date producer, state:

1. Name of producer: ___________________________________________________________________

2. Your title or capacity: ________________________________________________________________

When acting in my official capacity as a Committee representative, I shall engage in only those activities that are authorized under the date marketing order. I also understand that the Committee cannot become involved in lobbying and political activities. I will serve as a member or alternate member on the Committee if selected by the Secretary of Agriculture.

Signature: _________________________________________________ Date: _______________________

If any part of this questionnaire does not apply, please indicate such 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 10 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-285 (Rev. 01/2017) Destroy previous editions.