Get Usda Ad-755 1995

List your business experience. 11. List education and any specialized experience. Continued on reverse FORM AD-755 8/31/95 12. Form Approved O. M. B. No* 0505-0001 Expires 8/31/98 United States Department of Agriculture ADVISORY COMMITTEE MEMBERSHIP BACKGROUND INFORMATION 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 available for service on advisory committees. The information will be used to conduct background clearances and/or for annual reports on advisory committees. Failure to submit this information may result in nonselection of a prospective advisory committee member or termination of the committee. 1. Name Last First Middle 2. Social Security Number 3. Residence Address include ZIP Code 4. Telephone Home Office FAX 5. Place of Birth 6. Date of Birth 7. Name of Employer 8. Employer Address include ZIP Code 9. Your Occupation/Title 10. 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 13. List producer or farm 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. 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. 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. 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. If so please explain* 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 for which you are a nominee have any civil or criminal actions been initiated against you If so please explain* Signature Date Public reporting burden for this collection of information is estimated to average 30 minutes per response including the time for reviewing instructions searching for existing data sources gathering and maintaining the data needed and completing and reviewing the collection of information* Send comments regarding this burden estimate or aother aspectct of this collection of information including suggestions for reducing this burden to Department of Agriculture Clearance Officer OIRM Room 404-W Washington D*C* 20250 and to the Office of Management and Budget Paperwork Reduction Project OMB No* 0505-0001 Washington D*C* 20503. Form Approved O. M. B. No* 0505-0001 Expires 8/31/98 United States Department of Agriculture ADVISORY COMMITTEE MEMBERSHIP BACKGROUND INFORMATION 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 available for service on advisory committees. The information will be used to conduct background clearances and/or for annual reports on advisory committees. .