If you are interested in pursuing
membership with the NCACA, please complete the
form below.
This is a preliminary application. If you
qualify for membership, a full application in
pdf format
will be emailed to you to complete and return to
the NCACA Membership Chairman.
PERSONAL INFORMATION:
NAME:
ADDRESS:
CITY:
STATE:
ZIP: PHONE:
EMAIL:
NCDA Pesticide Consultant License Number:
BUSINESS
DATA:
BUSINESS NAME:
ADDRESS:
CITY:
STATE:
ZIP: PHONE:
FAX:
EMAIL: FOR WHICH MEMBERSHIP ARE YOU APPLYING?
EDUCATION:
UNDERGRADUATE:
SCHOOL NAME: LOCATION:
MAJOR/DEGREE EARNED:
GRADUATE/PROFESSIONAL:
SCHOOL NAME: LOCATION:
MAJOR/DEGREE EARNED:
OTHER FORMAL
EDUCATION:
SCHOOL NAME: LOCATION:
MAJOR/DEGREE EARNED:
EMPLOYMENT INFORMATION:
CURRENT EMPLOYER:
ARE YOU ON
STAFF AT AN ACADEMIC INSTITUTION?
IF YES, WHERE:
ARE YOU ENGAGED IN AGRICULTURAL CHEMICAL,
SEED, FERTILIZER, AND/OR OTHER AGRICULTURAL
MATERIALS SALES OR
APPLICATION FOR PERSONAL OR ASSOCIATED
PROFIT?
IF YES, PLEASE DESCRIBE:
PLEASE LIST ANY CURRENT PROFESSIONAL
MEMBERSHIPS YOU HOLD:
PLEASE LIST ANY CURRENT PROFESSIONAL
LICENSES AND CERTIFICATIONS YOU HOLD:
BRIEFLY SUMMARIZE YOUR RELEVANT WORK HISTORY
AND CONSULTING EXPERIENCE.
PLEASE GIVE APPROXIMATE DATES FOR EACH
REFERENCES: PLEASE PROVIDE
INFORMATION ON THREE INDIVIDUALS WHO HAVE
RECEIVED YOUR CONSULTING SERVICES
BUSINESS NAME: CONTACT NAME:
ADDRESS:
CITY:
STATE:
ZIP:
PHONE:
SERVICES PROVIDED:
BUSINESS NAME: CONTACT NAME:
ADDRESS:
CITY:
STATE:
ZIP:
PHONE:
SERVICES PROVIDED:
BUSINESS NAME: CONTACT NAME:
ADDRESS:
CITY:
STATE:
ZIP:
PHONE:
SERVICES PROVIDED:
BY CLICKING 'SUBMIT' YOU ARE AUTHORIZING
THE NCACA TO INVESTIGATE ALL STATEMENTS
CONTAINED IN THIS APPLICATION. YOU
ALSO ACKNOWLEDGE THAT ANY MISREPRESENTATION
OR OMISSION OF FACTS IS CAUSE FOR MEMBERSHIP
CANCELLATION AND THAT MEMBERSHIP IS
CONTINGENT UPON PAYMENT OF MEMBERSHIP DUES.
FULL MEMBERSHIP -
DUES ARE $100 ANNUALLY Full members of the NCACA:
1) Provide agricultural consulting and contract
research services for a fee
2) Hold a consultant's license from the NC
Department of Agriculture
3) Possess a four-year college degree in an
agricultural field
4) Have at least two years of reputable
experience in agricultural consulting or an
approved
combination of education or experience
5) Are not engaged in the sale or application of
agricultural chemicals, fertilizers, seed or
other
agricultural materials or equipment to grower clients
for profit. Only full members have voting privileges.
PROVISIONAL MEMBERSHIP -
DUES ARE $75 ANNUALLY Provisional members have all the
qualifications of a full member except for work
experience.
ASSOCIATE MEMBERSHIP -
DUES ARE $25 ANNUALLY Associate members serve on the staff of
an academic institution or regulatory agency and
can offer valuable technical information.
SUPPORTING MEMBERSHIP -
DUES ARE $200 MINIMUM
ANNUALLY
Supporting members are organizations with an
interest in agricultural consulting that wish to
financially support NCACA.
Affiliated MemberSHIP -
DUES ARE $75
ANNUALLY
Affiliated members are currently employed by a
company owned by a Full Member and is not
engaged in the sale or application of
agricultural chemicals, fertilizers, seed, or
other agricultural materials or equipment to
grower clients for personal or associated
business profit.
Affiliated members do not possess voting
privileges.
OUT OF STATE MEMBERSHIP -
DUES ARE $75
ANNUALLY
Out of state members consulting services for a
fee not within North Carolina.
STUDENT MEMBERSHIP -
DUES ARE $25
ANNUALLY
Student members are any college student
interested in the activitiesof the organization
whose curriculum is in an agricultural related
field.
