Application for Texas Organic Agricultural Industry Advisory Board

Texas Department of Agriculture

Application for Texas Organic Agricultural Industry Advisory Board
Deadline for Application: Dec. 18, 2015
SECTION A: APPLICANT INFORMATION
First Name
M.I.
Last Name
Primary Phone

Area CodePhone Number
Date of Birth

MonthDayYear
Email
MAILING ADDRESS
Address
City
State
Zip
County
Click here for application instructions.
SECTION B: CATEGORY OF APPLICANT
Check All That Apply

1. Member who is a producer of organic agricultural products2. Member who is a retail seller of organic agricultural products3. Member who is a distributor of organic agricultural products4. Member who is a processor of organic agricultural products5. Member who is representing a Texas trade association for the organic agricultural industry6. Member who is representing the Texas A&M AgriLife Extension Service7. Member who will serve as a technical advisor and is employed by: Member who will serve as a technical advisor and is employed by: 1) an institution of higher education; or, 2) a government agency as a researcher or instructor (see instructions for additional qualifications)8. Member who is representing the public
SECTION C: SUPPORTING DOCUMENTATION
Please provide information or documentation to support the categories selected in Section B. See instructions for additional information that is required to apply as a board member for each specific category.
If you'd like to attach supporting documentation, upload it here.

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SECTION D: CERTIFICATION STATEMENT
I hereby certify that:
- All information provided in connection with this application at any time is true and correct to the best of my knowledge and agree that any misrepresentation or false statement made in connection with this application will be grounds for disqualification to serve on the Texas Organic Agricultural Industry Advisory Board.
- I am not required to register as a lobbyist under Chapter 105 of the Government Code because of my activities for compensation on behalf of a profession related to the operation of TDA.
If appling as a “Member representing the public,” I certify that neither I, nor my spouse:
- Is certified or licensed by a regulatory agency in the field of organics;
- Is employed or participating in the management of a business entity or other organization regulated by or receiving funds from the Texas Department of Agriculture (TDA);
- Own or control, directly or indirectly, more than a 10 percent interest in a business entity or other organization regulated by or receiving funds from TDA; or
- use or receive a substantial amount of tangible goods, services or funds from TDA.
I authorize the Texas Department of Agriculture to conduct a background investigation in relation to this application, and understand that I will be required to provide my date of birth to facilitate this process. Failure to consent will result in rejection of this application.
SIGNATURE
Applicant Name (print)
Applicant Signature (Use mouse like pen)

Clear
Date

MonthDayYear
INSERT: This document becomes public record and is subject to disclosure. With few exceptions, you have the right to request and be informed about the information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. (Reference: Government Code, Sections 552.021, 552.023, and 559.004.)
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Texas Department of Agriculture

SECTION A: APPLICANT INFORMATION

MAILING ADDRESS

SECTION B: CATEGORY OF APPLICANT

SECTION C: SUPPORTING DOCUMENTATION

SECTION D: CERTIFICATION STATEMENT

SIGNATURE