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**

**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]{.underline}. (To be completed
by Advisory Committees Only)

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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

REPRODUCED LOCALLY: Include form number and date on all reproductions.
Form Approved O.M.B. No. 0505-0001

**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: