Application for Texas Wine Industry Development Advisory Committee

Texas Department of Agriculture

Application for Texas Wine Industry Development Advisory Committee
NOTE: Applications must be received by Sept. 30, 2015
Click here for instructions on filling out this application.
SECTION A: APPLICANT INFORMATION
Enter your full legal name, mailing address, primary telephone number, email and date of birth. Your date of birth is required for a criminal background check. Failure to provide this information will result in the rejection of your application. Providing your email allows us to send you important updates regarding your application and committee information in a timely manner.
First Name*
M.I.
Last Name*
Primary Phone*

Area CodePhone Number
Secondary Phone (optional)

Area CodePhone Number
Date of Birth

MonthDayYear
Email
MAILING ADDRESS
Address
City
State
Zip
County
SECTION B: CATEGORY OF APPLICANT
Check All That Apply

1. Grape grower in Texas2. Owner, operator or maker of wine in a Texas winery3. Researcher or educator specializing in enology or viticulture and employed by an institution of higher education, or a researcher or instructor employed by a government agency4. A representative of the Texas Alcoholic Beverage Commission5. A member of the public who is a consumer of Texas wine and not affiliated with the alcoholic beverage industry
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 Wine Industry Development Advisory Committee.

I further certify that:
• Neither I nor my spouse is employed by or participated 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 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;
• I authorize TDA to conduct a background investigation, including a criminal background check, in relation to this application.

NOTICE: This application becomes public record and is subject to disclosure. With few exceptions, you have the right to request and be informed about the information 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.).
SIGNATURE
Applicant Name (print)
Applicant Signature (Use mouse like pen)

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Date

MonthDayYear
Should be Empty:

Texas Department of Agriculture

SECTION A: APPLICANT INFORMATION

MAILING ADDRESS

SECTION B: CATEGORY OF APPLICANT

SECTION C: SUPPORTING DOCUMENTATION

SECTION D: CERTIFICATION STATEMENT

SIGNATURE