| Peer Reviewer Application and Qualifications Form |
| For the Federal-State Marketing Improvement Program (FSMIP) |
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| Complete this form to indicate your qualifications to review FSMIP grant applications. Additional instructions on how to Become an Application Reviewer are at the FSMIP website: http://www.ams.usda.gov/services/grants/fsmip. |
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First Name |
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| Email |
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| Phone |
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Fax |
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| Street Address |
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| City |
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State |
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Zip Code |
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| Academic Background |
| Highest Degree Completed |
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| Degree Area |
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| Profession/Rank |
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| Employer Name |
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| Employer Type |
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Federal Employee |
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State Agriculture Dept. |
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Land Grant University/College |
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Other State University/College |
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Other State Agency (specify): |
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| Percent of Academic Appointment (if applicable) |
| Appointment |
Percent |
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| Research |
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| Teaching |
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| Extension/Outreach |
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| Administration |
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| Total |
0 |
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| Demographic Information (Optional) |
| Gender |
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| Race |
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| Ethnicity |
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| Previous Federal Grant Application Review Experience |
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| Potential Conflict(s) of Interest |
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| Expertise (check as many as appropriate) |
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Ag/Resource Economics |
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New Uses for Ag Products |
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Aquaculture |
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Consumer Economics/WTP |
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Post-Harvest Handling |
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Bioenergy |
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Extension |
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Price Discovery |
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Dairy |
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Food/Ag Marketing |
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Product Devel/Testing |
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Forestry/Wood Products |
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Food Safety |
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Producer Training/Tech Assist |
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Grain/Oilseeds |
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Foreign Mkt Devel/Exports |
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Rural Economic Devel |
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Horticulture/Nursery |
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Labeling/Branding |
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Transp/Logistics/Distribution |
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Livestock, Meat, Poultry |
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Local/Regional Food Systems |
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Quality/Standards |
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Specialty Crops |
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| 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- -0240. The time required to complete this information collection is estimated to average 15 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, age, disability, and where applicable sex, marital status, or familial status, parental status religion, sexual orientation, genetic information, political beliefs, reprisal, or because all or part of an individual’s income is derived from any public assistance program (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, 1400 Independence Avenue, SW, Washington, DC 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TDD). USDA is an equal opportunity provider and employer. |