AD-755 Background Information

Form – AD-755 Approved OMB No. 0581-0263

Expiration Date: 09/30/2019

United States Department of Agriculture

ADVISORY COMMITTEE OR RESEARCH AND PROMOTION

BACKGROUND INFORMATION

National Sheep Industry Improvement Center

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.

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:

Email 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. Of the following, in which industry(s) are you currently engaged:

Sheep or goat _____; Finance or management _____; Lamb, wool, goat _____; Goat product marketing _____

How long have you been involved in your respective industry(s)?

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. 0581-0263

Expiration Date: 09/30/2019

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.

National Sheep Industry Improvement Center

Name (Last, First, Middle)

Social Security or Passport Number:

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 0581-0263. 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.

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.

Form – AD-755 Approved OMB No. 0581-0263

Expiration Date 09/30/2019

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.