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Form – AD-755   										            Approved OMB No. 0581-0263
                               Expiration Date:  09/30/2019	
United States Department of Agriculture 
ADVISORY COMMITTEE OR RESEARCH AND PROMOTION 
BACKGROUND INFORMATION
National Sheep Industry Improvement Center







PLEASE PRINT CLEARLY OR TYPE 

1. Name (Last, First, Middle) – Mr., Mrs., Miss., Ms., Dr.	  2.  Social Security Number:  
	
        Passport Number and Issuing Country: (foreign citizens only) 
			

3. Residential Address (include ZIP code):                                      4. Business No.: 
							         Home No.:
							         Cell or Mobile:
         FAX:
	  Email Address:

5.  Place of Birth:				 	  	  6. Date of Birth:
	
7.  This information is Voluntary and data will not be used to grant preferential treatment:  (See last page for definition of categories.)
     What is your gender?	     	Ethnicity:  			What is your race? (Mark one or more)
      ___ Male    		      	___ Hispanic or Latino		___ American Indian or Alaska Native
      ___ Female	    	      	___ Not Hispanic or Latino	___ Asian
								___ Black or African American
								___ Native Hawaiian or Other Pacific Islander
								___ White        
8. Company/Business Name:					8a.  Are you a federally registered lobbyist?			

						
9.  Company/Business Address (include ZIP Code):	  			9a.  Occupation/Title:
				
										

			
10.  Of the following, in which industry(s) are you currently engaged:
      Sheep or goat _____;   Finance or management _____;   Lamb, wool, goat _____;   Goat product marketing _____

      How long have you been involved in your respective industry(s)?  







10a. If applicable, how long have you been engaged in farming or production, and what is the size of your farming operation. (i.e.
        List acreage and pounds produced by kind of crop, as well as, kinds and numbers of livestock?)







11.  List your business experience. (Use the Continuation Sheet for additional space to answer.)





12.  List education and any specialized experience. (Use the Continuation Sheet for additional space to answer.)







13.  List applicable farm/handler/producer/importer or co-op member industry organizations (indicate whether a member or officer and how long affiliated).





14.  List other affiliations and/or service as a community leader that would benefit you in your role as a member of the advisory committee or research and promotion board/council.





15.  List any Federal advisory committee or board on which you are currently a member and the number of years you have served on that committee or board. (To be completed by current Advisory Committee Members Only)




16.  List sources of income in excess of $10,000 for the past calendar year from other than your primary employment.  List only sources; do not show amounts of income from each source.  (To be completed by Advisory Committee Nominees Only) 

       _________________________________	_____________________________________

       _________________________________	_____________________________________


17.  Have you ever been convicted of a felony?  (A felony is defined as any violation of law punishable by imprisonment of longer than one year).    (     ) Yes     (     ) No.    If yes, please explain on the attached continuation sheet.

18.  As a result of your participation in Federal programs, have any judgments been rendered against you?  As a result of participation in any governmental programs relative to the purposes of the advisory committee or research and promotion board/council for which you are a nominee, have any civil or criminal actions been initiated against you?  
       (     ) Yes     (     ) No.    If yes, please explain on the attached continuation sheet.


19.  Name as you would prefer it to appear on official correspondence. 



Signature	   Date







.											        Approved OMB No. 0581-0263
                    Expiration Date: 09/30/2019

Continuation Sheet for Form AD-755

If you need more space for an answer, use this sheet.  Please number each answer to correspond to the number on Form AD-755.  When you have completed your answer(s), attach to Form AD-755.

National Sheep Industry Improvement Center

	

Name (Last, First, Middle)		                                                                                                                     

Social Security or Passport Number:		                                                                                                        




























Form – AD-755    Approved OMB No. 0581-0263
Expiration Date 09/30/2019
Definition of Ethnicity and Race Categories


Ethnicity:  
Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.

Race:
American Indian or Alaska Native – A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam.

Black or African American – A person having origins in any of the black racial groups of Africa.

Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.

White – A person having origins in any of the original peoples of Europe, the Middle East, or North Africa.