OMB No. 0581-0178

SC-125 (Rev. 5/2017) Destroy previous editions.

UNITED STATES DEPARTMENT OF AGRICULTURE

AGRICULTURAL MARKETING SERVICE

SPECIALTY CROPS PROGRAM

CONFIDENTIAL CALIFORNIA WALNUT BOARD NOMINEE QUESTIONNAIRE

PUBLIC MEMBER/ALTERNATE 

The following information is needed and used by the Secretary of Agriculture to determine the eligibility and 

willingness of nominees to serve on the California Walnut Board (Board) under Federal Marketing Order No. 984. 

Failure to provide this information may hinder your selection by the Secretary.

1. Name: ___________________________________________________________________________________

2. (a) Residence: _____________________________________________________________________________

(Street, City, State, and Zip Code)

(b) Mailing Address: (if same, so state) _________________________________________________________

(Street, City, State, and Zip Code)

(c) Telephone Number: (H) __________________ (W) __________________ (C) __________________

(d) E-mail Address: _________________________________________________________________________

3. Occupation – Employer ______________________________________________________________________

4. Organizations to which you belong _____________________________________________________________

__________________________________________________________________________________________

5. Have you previously served on the California Walnut Board? □ Yes □ No; if yes, for how many years? _____

6. Are you a walnut grower? □ Yes □ No

7. Are you affiliated with a walnut handler (packer) as an employee, officer, director, or in any other capacity?

□ Yes □ No

8. When acting in my official capacity as a Board representative, I shall engage in only those activities that are 

authorized under the walnut marketing order. I also understand that the Board cannot become involved in 

lobbying and political activities.

9. I hereby certify that I am willing to serve as a member or alternate member on the California Walnut Board if 

selected by the Secretary of Agriculture.

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 0581-

0178. 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.