EmailMe Form - GAIAC Membership Application

Membership Category

Please select the membership category for which you are applying.

Name

Prefix First Last Suffix

Company Name

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Email

Phone Number

CURRENT AGRICULTURAL AREA OF EXPERTISE:

YOUR ASSOCIATIONS, EDUCATION & EXPERIENCE

ARE YOU CURRENTLY A MEMBER IN ANY PROFESSIONAL ASSOCIATIONS?

YES

NO

NAME OF ORGANIZATIONS, REGISTRIES, ASSOCIATIONS TO WHICH YOU BELONG:

ARE YOU A MEMBER IN A PROFESSIONAL AGRICULTURAL SOCIETY?

YES

NO

NAME OF SOCIETY OR SOCIETIES TO WHICH YOU BELONG:

COLLEGE OR UNIVERSITY ATTENDED:

YOUR MAJOR OR FIELD OF STUDY:

DEGREE YOU RECEIVED:

DATE YOU RECEIVED YOUR DEGREE (YEAR):

DATE ON WHICH YOU FIRST PERFORMED INDEPENDENT CONSULTING, RESEARCH FOR A FEE:

APPROXIMATE PORTION OF YOUR TIME SPENT CONSULTING FOR A FEE DURING THE CURRENT YEAR (PERCENT)

APPROXIMATE PORTION OF YOUR TIME SPENT CONSULTING FOR A FEE DURING THE PREVIOUS TWO YEARS (PERCENT)

APPROXIMATE PORTION OF YOUR TIME SPENT CONSULTING FOR A FEE DURING THE PREVIOUS YEAR (PERCENT)

DO YOU PROVIDE RECOMMENDATIONS AND/OR TECHNICAL DATA ON A FEE BASIS?

YES

NO

ARE YOUR FEES ITEMIZED AND BILLED TO THE CLIENT?

YES

NO

NA

DO YOU CURRENTLY RECEIVE COMPENSATION FROM A CLIENT'S PURCHASE OF PRODUCTS BASED ON YOUR RECOMMENDATIONS OR DATA?

(Products include inorganic or organic fertilizers, seeds, commercially available equipment, chemical or biological pest control materials, or animal feed or medicinal products)

YES

NO

REFERENCES AND ACKNOWLEDGEMENT

REFERENCES: Please provide names and addresses of three of your client references who can attest to your qualifications, services, and professionalism. Attach letters of recommendation to this application form.

Reference Name

First Last

Company Name

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Reference Name

First Last

Company Name

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Reference Name

First Last

Company Name

Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

I certify that all preceding information is accurate to the best of my knowledge and I have read and agree to comply with the Bylaws and Code of Ethics for the
Global Alliance of Independent Agricultural Consultants. *

AGREE