Fillable Stelprdb5150773 Form Approved O

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Stelprdb5150773 Form Approved O

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Form – AD-755 Approved OMB No. 0505-0001
Expiration Date: 9/30/2018
United States Department of Agriculture
ADVISORY COMMITTEE OR RESEARCH AND PROMOTION
BACKGROUND INFORMATION
[Insert the board/council name below]
PLEASE PRINT CLEARLY OR TYPE
1. Name (Last, First, Middle) – Mr., Mrs., Miss., Ms., Dr. 2. Social Security Number:
Passport Number and Issuing Country: (foreign citizens only)
3. Residential Address (include ZIP code): 4. Business No.
Home No:
Cell or Mobile:
FAX:
e-Mail Address:
5. Place of Birth: 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.)
What is your gender? Ethnicity: What is your race? (Mark one or more)
___ Male ___ Hispanic or Latino ___ American Indian or Alaska Native
___ Female ___ Not Hispanic or Latino ___ Asian
___ Black or African American
___ Native Hawaiian or Other Pacific Islander
___ White
8. Company/Business Name: 8a. Are you a federally registered lobbyist?
9. Company/Business Address (include ZIP Code): 9a. Occupation/Title:
10. [Insert appropriate commodity question(s) from supplemental list.] (To be completed by R&P Board Members Only)
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.
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 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 current Advisory Committee Members 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 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 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.
Signature Date
. Approved OMB No. 0505-0001
Expiration Date: 9/30/2018
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 or Passport Number:
Form – AD-755 Approved OMB No. 0505-0001
Expiration Date 9/30/2018
Definition of Ethnicity and Race Categories
Ethnicity:
Hispanic or Latino. A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish
culture or origin, regardless of race.
Race:
American Indian or Alaska Native – A person having origins in any of the original peoples of North and
South America (including Central America), and who maintains tribal affiliation or community attachment.
Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian
subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the
Philippine Islands, Thailand, and Vietnam.
Black or African American – A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of
Hawaii, Guam, Samoa, or other Pacific Islands.
White – A person having origins in any of the original peoples of Europe, the Middle East or North Africa.
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, and marital or family status. (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.
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Completed 20 February 2020

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