Ad-755 Advisory Committee Or Research And Promotion Background

United States Department of Agriculture (USDA)

Form – AD-755 Approved OMB No. 0505-0001
Expiration Date: 12/31/2025

ADVISORY COMMITTEE OR COMMODITY BOARD
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 commodity boards.
Failure to complete and submit the AD-755 Advisory Committee or Commodity Background Information Form may result in nonselection 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.

2. Social Security Number:
Are you a U.S. Citizen? (Mark yes or no) ☐ Yes

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

☐ No

(foreign citizens only) If no, please provide passport number,
expiration date, and issuing country:
4. Business Phone:

3. Residential Address (include ZIP code):

Home Phone:
Mobile Phone:
3a. If foreign national, have resided in U.S. for 3 years or
more continuous years?

☐ Yes

☐ No

5. Place of Birth (City and State, Country):

Fax #:
E-mail Address:
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.)
Race and/or Ethnicity: (Mark all that apply)

Sex:
☐ Male

☐ Female

Veteran:
☐ Yes

☐ Asian
☐ Black or African American

☐ No

Disability/Impairment:
☐ Yes

☐ American Indian or Alaska Native

☐ No

8. Company/Business Name:

☐ Hispanic or Latino
☐ Middle Eastern or North African
☐ Native Hawaiian or Pacific Islander
☐ White
8a. Are you a federally registered lobbyist? ☐ Yes ☐ No
If yes, provide registrant identification #:

9. Company/Business Address (include Zip Code):

9a. Occupation/Title:

10. Complete appropriate commodity question(s) from supplemental list forms. (For AMS Commodity Boards Only)
Placeholder for Hyperlink to: AD-755 Supplemental List Form for AMS Research & Promotion Board Candidates Only
Placeholder for Hyperlink to: AD-755 Supplemental List Form for AMS Marketing Order Board Candidates Only

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 commodity board.

15. If currently serving on a USDA federal advisory committee or commodity 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:

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

Approved OMB No. 0505-0001
Expiration Date: 12/31/2025

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 12/31/2025

Race and

Ethnicity: i

Definition of Categories

American Indian or Alaska Native. Individuals with origins in any of the original peoples of North,
Central, and South America, including, for example, Navajo Nation, Blackfeet Tribe of the Blackfeet
Indian Reservation of Montana, Native Village of Barrow Inupiat Traditional Government, Nome Eskimo
Community, Aztec, and Maya.
Asian – Individuals with origins in any of the original peoples of Central or East Asia, Southeast Asia, or
South Asia, including, for example, Chinese, Asian Indian, Filipino, Vietnamese, Korean, and Japanese.
Black or African American – Individuals with origins in any of the Black racial groups of Africa,
including, for example, African American, Jamaican, Haitian, Nigerian, Ethiopian, and Somali.
Hispanic or Latino. Includes individuals of Mexican, Puerto Rican, Salvadoran, Cuban, Dominican,
Guatemalan, and other Central or South American or Spanish culture or origin.
Middle Eastern or North African. Individuals with origins in any of the original peoples of the Middle East
or North Africa, including, for example, Lebanese, Iranian, Egyptian, Syrian, Iraqi, and Israeli.
Native Hawaiian or Pacific Islander. Individuals with origins in any of the original peoples of Hawaii,
Guam, Samoa, or other Pacific Islands, including, for example, Native Hawaiian, Samoan, Chamorro,
Tongan, Fijian, and Marshallese.
White. Individuals with origins in any of the original peoples of Europe, including, for example, English,
German, Irish, Italian, Polish, and Scottish.
Mark all that apply – A person having two or more origins in any race and/or ethnicity.
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).
These race and ethnicity definitions are in accordance with the Office of Management and Budget (OMB) revisions to the Statistical
Policy Directive No. 15: Standards for Maintaining, Collecting, and Presenting Federal Data on Race and Ethnicity (SPD 15).
i