AD-755 Advisory Committee or Research and Promotion Background

Form – AD-755

United States Department of Agriculture (USDA)

Approved OMB No. 0505-0001
Expiration Date: xx/xx/2022

ADVISORY COMMITTEE OR RESEARCH AND PROMOTION
BACKGROUND INFORMATION

Advisory Committee/
Commodity Board Name:

Privacy Act Notice
Public Laws 95-113 and 93-579 permit collection of the data requested on this form. The information is used to determine qualifications, suitability
and availability for service on advisory committees or research and promotion boards/councils. The information will be used to conduct
background clearances and/or for annual reports on advisory committees or research and promotion boards/councils.
Failure to complete and submit the AD-755 Advisory Committee or Research and Promotion Background Information Form may
result in non-selection of a prospective advisory committee/board member to serve on an USDA advisory committee/commodity board.

PLEASE PRINT CLEARLY OR TYPE
1. Legal Name (Last, First, Middle) Mr., Mrs., Miss., Ms., Dr.

1a. Name as you would prefer it to appear on official correspondence.

2. Social Security Number:
Are you a U.S. Citizen? (Mark yes or no) ____(yes)____(no)
If no, please provide passport number and issuing country:
(foreign citizens only)
4. Business Phone:

3. Residential Address (include ZIP code):

Home Phone:
Mobile Phone:
Fax #:
E-mail Address:
5. Place of Birth (City and State, Country):

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.)
Sex:

Race: (Mark one or more)

Ethnicity:
Male

Female

Veteran:
Yes

Hispanic or Latino

American Indian or Alaska Native

Not Hispanic or Latino

Asian

Disability/Impairment:
No

Yes

No

Black or African American
Native Hawaiian or Other Pacific Islander
White

8. Company/Business Name:

8a. Are you a federally registered lobbyist?

Yes

If yes, provide registrant identification #:
9. Company/Business Address (include Zip Code):

9a. Occupation/Title:

10. [Insert appropriate commodity question(s) from supplemental list.] (To be completed by R&P Board Members Only)

No

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. If currently serving on a USDA federal advisory committee, council, or board, identify the name and include the original
membership term start date and term end date (XXXX/XX/XXXX – XXXX/XX/XXXX).

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/liens 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. Print Name & Sign:

Signature:

Date:

RESET FORM

REPRODUCED LOCALLY: Include form number and date on all reproductions.

Approved OMB No. 0505-0001
Expiration Date: xx/xx/2022

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.
[INSERT ADVISORY COMMITTEE/COMMODITY BOARD NAME]

Name (Last, First, Middle):
Last 4 digits of Social Security or Passport Number:
Additional space for answers (if needed):

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 0505-0001. The time required
to complete this information collection is estimated to average 30 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.
The U.S. Department of Agriculture (USDA) prohibits discrimination in all its programs and activities on the basis of race, color, national origin, religion,
sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, family/parental status, political beliefs, 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). (Not all prohibited bases apply to all programs.) Persons with disabilities who require alternative means for
communication of program information (Braille, large print, audiotape, etc.) should contact USDA’s TARGET center at (202) 720-2600 (voice and TDD).
To file a complaint of discrimination, write USDA, Director, Office of Civil Rights, Room 326-W, Whitten Building, 1400 Independence Avenue, SW,
Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.

Form – AD-755 Approved OMB No. 0505-0001
Expiration Date xx/xx/2022

Definition of 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.
Two or more – A person having two or more origins in any race.
Individual with a Disability:
A person who (1) has a physical impairment or mental impairment (psychiatric disability) that substantially
limits one or more of such person's major life activities; (2) has a record of such impairment; or (3) is
regarded as having such an impairment. This definition is provided by the Rehabilitation Act of 1973, 29
U.S.C. 701 et. seq., as amended.
Veteran:
The term "veteran" means a person who served in the active military, naval, or air service, and who was
discharged or released therefrom under conditions other than dishonorable, This definition is provided by
38 U.S. Code § 101 (2).