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Failure to submit this information may result in nonselection of a prospective advisory committee member or termination of the committee. 1. Name Last First Middle 2. Social Security Number 3. Residence Address include ZIP Code 4. Telephone Home Office FAX 5. Place of Birth 6. Date of Birth 7. Name of Employer 8. Employer Address include ZIP Code 9. Your Occupation/Title 10. If applicable how long have you been engaged in farming or production and what is the size of your farming operation i*e* ...

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