Form DI Form 9009 DI Form 9009 Federal Subsistence Regional Advisory Council Membership

DI Form 9008 (Rev. 09/2024) OMB Control No. 1090-New

U.S. Department of the Interior Expires ##/##/20##

INCUMBENT APPLICATION FORM

Federal Subsistence Regional Advisory Council Membership

Office of Policy, Management, and Budget

Office of Subsistence Management

APPLICANT’S FULL NAME:

                 

First Middle Last

Full mailing address:

                       

Street Address City State Zip Code

Contact Information:

                 

Home Phone: Work Phone: Fax:

Email:       Birthdate:      

PLEASE ANSWER THE FOLLOWING QUESTIONS (ATTACH ADDITIONAL PAGES IF NEEDED):

1. Where is your (or your nominee’s) primary place of residence? (Please note that members must reside in the region they represent.)

     

2. Describe any updates or changes to answers you provided in your last fully completed Application/Nomination Form (DI Form 9009).

     

3. Why do you wish to continue serving on the Regional Advisory Council? What would be your goals for another term?

     

4. Regional Council membership should reflect representation of subsistence and commercial/ sport interests. Regional Council seats are designated for either subsistence use or commercial/ sport use representatives. You must choose one or the other.

Subsistence Commercial/Sport

5. Reference Contacts: Please include three references and their contact information. Please provide the most current phone numbers available. If you wish, you may also submit letter(s) of recommendation.

Name:      

Organization:      

Contact Information: Home Phone: (907)       Work Phone: (907)      

^{Address:      }

Zip:       E-mail:      

Name:      

Organization:      

Contact Information: Home Phone: (907)       Work Phone: (907)      

^{Address:      }

Zip:       E-mail:      

Name:      

Organization:      

Contact Information: Home Phone: (907)       Work Phone: (907)      

^{Address:      }

Zip:       E-mail:      

I certify, to the best of my knowledge, that all statements are correct and complete.

Signature Date

Please note: All applications must be signed in ink. No application or nomination will be considered complete without a signature.

NOTICES

PRIVACY ACT STATEMENT

Authority: The information requested is authorized by the Alaska National Interest Lands Conservation Act; 36 CFR 242 and 43 CFR 51.

Purpose: The applicant’s information will be used to evaluate their qualifications and experience for the potential selection to serve as a member on one of the Federal Subsistence Regional Advisory Councils.

Routine Uses: The Federal Subsistence Board will use the provided information to make recommendations to the Secretaries of Interior and Agriculture for the appointment of members to the Federal Subsistence Regional Advisory Councils. More information about routine uses can be found in the System of Records Notice, Permits System, FWS-21.

Disclosure: Providing the information is voluntary but required to obtain or retain a benefit.

PAPERWORK REDUCTION ACT STATEMENT

In accordance with the Paperwork Reduction Act (44 U.S.C. 3501, et seq.), the Office of Subsistence Management collects information necessary to make recommendations to the Secretaries of the Interior and Agriculture for appointment of members to the Federal Subsistence Regional Advisory Councils. It is our policy not to use your name for any other purpose. Your response is voluntary but is required to obtain or retain a benefit. 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 currently valid OMB control number. OMB has approved this collection of information and assigned Control No. 1090-####.

ESTIMATED BURDEN STATEMENT

We estimate public reporting for this collection of information 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. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the Departmental Information Collection Clearance Officer, 1849 C Street, NW Washington, DC 20240, or via email at [email protected]. Please do not send your completed form to this address.

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