| 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
APPLICATOR LICENCE AND/OR CERTIFICATION NUMBER:
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| SECTION B |
COLLEGE or UNIVERSITY
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EDUCATION:
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MAJOR
DEGREE
DATE RECEVIED
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EXPERIENCE:
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List briefly since graduation from college or during past ten years.
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PRESENT EMPLOYER:
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EMPLOYER NAME:
EMPLOYER ADDRESS:
CITY:
STATE
ZIP
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:
Do you generate technical data to clients on a fee basis?
yes
no
If not, what services for a fee do you provide?
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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 within the past 3 years, give the name of the
individual (Study Director, etc.) who contracted the work. Please FILL IN COMPLETELY.
These references should be able to verify the information provided above.
References (5 required)
1.
2.
3.
4.
5.
List professional registries and associations in which you are active
or hold membership
Please indicate if you were recruited by a current NAICC member:
Name:
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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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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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