Get Ad 755 2019-2024

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. 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 AD-755 10/02 11. REPRODUCED LOCALLY Include form number and date on all reproductions. Form Approved O. M. B. No* 0505-0001 United States Department of Agriculture ADVISORY COMMITTEE OR RESEARCH AND PROMOTION BACKGROUND INFORMATION Insert the board/council name here 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 9. Occupation/Title 10. Insert appropriate commodity question s from supplemental list. 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 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.