United States Department of Agriculture
ADVISORY COMMITTEE OR RESEARCH AND PROMOTION
BACKGROUND INFORMATION 

[Deschutes-Ochoco Resource Advisory Committee]                      

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 submit this information may result in non-selection of a prospective advisory committee member, board/council member or termination of the committee or board/council.

PLEASE PRINT CLEARLY OR TYPE

1. Name (Last, First, Middle)
     
 	 2. Social Security Number
          	
3. Residence Address (include ZIP code)
         		 4. Business No.
          
     Home No:
          
     FAX:
          
     e-Mail Address:
          	
5. Place of Birth 
     	 6. Date of Birth
          	
7. Company/Business Name
         	
8. Company/Business Address (include ZIP Code)
         	
	 9. Occupation/Title
                                                         	
10. [Insert appropriate commodity question(s) from supplemental list.] To be completed by R&P Board Members 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.
     

	
12. List education and any specialized experience.
     

	
13. List applicable farm/handler/producer/importer or co-op member industry organizations (include 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 Advisory Committees 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 Committees 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. (To be completed by R&P Board Members Only) 
     
	
Signature
	Date
     	

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, gender, religion, age disability, political beliefs, sexual orientation, marital or family status, political beliefs, parental status or protected genetic information. (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, 14th and Independence Avenue, SW, Washington, DC 20250-9410 or call (202) 720-5964 (voice and TDD). USDA is an equal opportunity provider and employer.

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 COMMODITY BOARD,COUNCIL,OR DELEGATE NAME]

Name (Last, First, Middle)           

Social Security Number: