| SECTION A |
FIRST NAME
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APPLYING FOR:
Provisional
Voting
Associate
Additional member from the same company
Student
Retired
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MIDDLE NAME
LAST NAME :
BUS.PHONE:
HOME PHONE:
FAX
MOBILE PHONE:
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COMPANY
ADDRESS
CITY
STATE
ZIP
EMAIL
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| SECTION B |
Does your state have a crop consulting association?
yes
no
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If yes, are you a member in good standing?
yes
no
State Cetification Number
Category
State license Number
Category
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EDUCATION:
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COLLEGE or UNIVERSITY
MAJOR
DEGREE
DATE RECEVIED
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INDEPENDENT CONSULTING EXPERIENCE:
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List briefly since graduation from college or during past ten years.
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EMPLOYMENT:
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EMPLOYER NAME:
EMPLOYER ADDRESS:
CITY:
STATE
ZIP
POSITION:
LENGHT of SERVICE:
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PROFESSIONAL EXPERIENCE:
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Date on which work was first performed in the contract research field:
Please indicate the approximate amount of time spent in the contract research area during
the last 4 years:
Current Year %
Last Year %
Previous Years %
Number of years prior to the last four years that you were engaged in
contract research activities:
Describe your field of consultation or speciality during the last four years. Include
crops consulted and servoces provided.
Do you generate technical data to clients on a fee basis?
yes
no
Are your fees itemized and billed to the client?
yes
no
Do you currently receive any compensation from a client's purchase of products*
based on your recommendations or data?
yes
no
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*Definition of products:
- Inorganic or organic fertilizers or soil amendments
- Seed or plant materials
- Commercially available equipment, machinery, or implements
- Chemical or biological pest-control inputs
- Animal feed or medicinal products
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If you are employed by a company, is your compensation supplemented or
subsidized by income derived from the sale of products, as defined above?
yes
no
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ELEGIBILITY:
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A secondary review mechanism is available to be utilized in cases in which either
the applicant or the membership committee is uncertain whether the applicant meets the criteria
described. If you are uncertain of your eligibility and would like more information,
please indicate.
yes, I am uncertain,
no
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REFERENCES:
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Please give the name, address, and phone number of five of your
clients. If work was done for a company, give the name of the
individual for whom you worked. Please FILL IN COMPLETELY.
1.
2.
3.
4.
5.
List professional registries and associations in which you are active
or hold membership
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SPONSORS: |
Provisional and Voting Members Only. * Please list two NAICC members as sponsors. Include their
names, addresses, and phone numbers
1.
2.
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PUBLICITY: |
List the names, addresses and phone numbers of local newspapers
where press releases can be sent:
1.
2.
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CERTIFICATION: |
By selecting "YES" below and submitting this form, I certify that all preceding information
is accurate to the best of my
knowledge. I have read, understand, and agree to comply with the Bylaws and Code of Ethics
for the National Alliance of
Independent Crop Consultants.
yes no
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MEMBERSHIP DUES: |
Provisional/Voting/Associate ... $225.00
Additional P/V/A member from the same company *... $175.00
* Multi-member discount: If your company has two or more employees that are NAICC members or who are eligible for membership, your company qualifies for the $50 discount. The first member from the company pays full membership dues of $195. Each employee after the first pays dues of $145.
Student ................. $10.00
Retired ................. $65.00
NAICC requires a non-refundable $25.00 application fee in addition to membership dues to cover processing and membership evaluation. This fee is not applied to students.
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