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UNITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

SPECIALTY CROPS PROGRAM

Background/Acceptance Statement for Industry Members and Alternates

CONFIDENTIAL BACKGROUND STATEMENT

The following information will be used by the Secretary of Agriculture in selecting a representative to serve 

on the ______________. The ________________ administers Federal Marketing Order No. ___, which 

regulates the handling of ______________ grown in ________________________. Statutory authority to collect 

the information is provided in 7 U.S.C. §§ 601-674. Failure to provide this information may hinder your selection 

by the Secretary. Please provide information applicable to the position to which nominated. This information is 

required to determine the nominee’s eligibility and willingness to serve and will be treated confidentially.

POSITION: _______________________________ TERM OF OFFICE: _________

NAME:(as you would like it to appear on official corespondence) EMAIL ADDRESS:

BUSINESS ADDRESS: (NOTE: If a handler, also show firm name and in what capacity you serve in such firm)

TELEPHONE NUMBER: (Include area code) FAX NUMBER: (Include area code)

HAVE SERVED PREVIOUSLY AS: (Mark an “X” in the appropriate box)

□ MEMBER □ ALTERNATE MEMBER

YEARS IN INDUSTRY (include growing and/or 

handling) __________

IS YOUR OPERATION CERTIFIED ORGANIC?

(fully of partially) □ Yes □ No

PRODUCTION LAST SEASON. (if grower)

(Please include acres and volume)

IS YOUR OPERATION SMALL? (as defined by the Small 

Business Administration for a GROWER as having annual recipets 

less than $750,000 and a HANDLER as those whose annual receipts 

are less than $7,500,000 (13 CFR 121.201).

□ Yes □ No

APPROXIMATE VOLUME HANDLED LAST SEASON (if handler)

LIST OFFICES HELD OR MEMBERSHIP IN ORGANIZATIONS IN THE PAST FEW YEARS CONNECTED 

WITH INDUSTRY PROGRAMS:

LIST OF ALL SALES CONSTITUENCIES (MARKETING OR BROKERAGE GROUPS):
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Members, in their official capacities, are prohibited from taking any action specifically designed to influence 

legislation, including any attempt to influence public opinion concerning legislation. Members, in their official 

capacity, may not communicate with any official of a State or Federal legislative body for the purpose of attempting 

to influence legislation. Members are also prohibited from attempting to influence state or Federal government 

actions or policies or those of foreign governments, except as specifically authorized under the Marketing Order or 

expressly approved by the Secretary. Members are specifically precluded from authorizing the expenditure of 

Marketing Order funds for the purpose of attempting to influence legislation or government actions. These same 

prohibitions apply to managers, staff, and contractors except that managers may consult with U.S. Department of 

Agriculture (USDA) employees during the pendency of informal rulemaking actions.

If members, subcommittee members or employees are sued individually or jointly for errors in judgment, mistakes 

or other acts either of omission or commission (except for acts of dishonesty, willful misconduct, or gross 

negligence) in the conduct of their duties under the Marketing Agreement or Order, they may be authorized legal 

defense by the Department of Justice (DOJ). Alternatively, legal defense may be provided through private counsel, 

if recommended by USDA and approved by DOJ. USDA and DOJ enjoy an excellent working relationship with 

respect to providing legal representation for members and employees, either by DOJ or through authorized private 

counsel. USDA is committed to a comprehensive legal defense policy for all members and employees acting within 

the scope of their authorized duties and responsibilities.

Acceptance Statement: If selected, I accept the appointment and agree to serve during the 

period for which I am appointed and until my successor has been selected and qualified. I 

also agree that I will carry out assigned duties in administering the terms and provisions of 

the marketing order to the best of my ability. When acting in my official capacity 

representative, I shall engage in only those activities that are authorized under the 

marketing order.

Name (print): _________________________________________

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 OMB 

0581-0177. The time required to complete this information collection is estimated to average 5 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.

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its 

Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on 

race, color, national origin, religion, sex, gender identity (including gender expression), sexual orientation, disability, age, marital status, 

family/parental status, income derived from a public assistance program, political beliefs, or reprisal or retaliation for prior civil rights activity, in 

any program or activity conducted or funded by USDA (not all bases apply to all programs). Remedies and complaint filing deadlines vary by 

program or incident.

Persons with disabilities who require alternative means of communication for program information (e.g., Braille, large print, audiotape, American 

Sign Language, etc.) should contact the responsible Agency or USDA’s TARGET Center at (202) 720-2600 (voice and TTY) or contact USDA 

through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English. 

To file a program discrimination complaint, complete the USDA Program Discrimination Complaint Form, AD-3027, found online at 

http://www.ascr.usda.gov/complaint_filing_cust.html and at any USDA office or write a letter addressed to USDA and provide in the letter all of 

the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to 

USDA by: (1) mail: U.S. Department of Agriculture Office of the Assistant Secretary for Civil Rights 1400 Independence Avenue, SW 

Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: program.intake@usda.gov. USDA is an equal opportunity provider, 

employer, and lender.