IICCA Membership Form

Name                                                                                                                                    

Organization                                                                                                                           

Title                                                                                                                                     

Work Address                                                                                                               

City                                               State             Zip                                                               

Phone                                            Fax                                    e-mail                                       

Home Address                                                                                                                        

City                                               State             Zip                                                               

Phone                                            Fax                                    e-mail                                       

Membership Class please check one

  Voting - Certified ($75)            Provisional  ($75)       Student  ($10)        Affiliate ($50)

   Voting – Non-Certified ($75)       Academic  ($50)        Sustaining ($300) – see other form

 

Education

Highest Degree Attained                                                  Date Received                                       

College or University                                             Major                                                            

 

Academic Members

List your position and classification if connected with a college or university:                                                                                                                                                                                   

 

Year Started as Independent Consultant  for Voting & Provisional Membership status

                   

 

Independent Consulting Business for Voting & Provisional Membership status

·        Please indicate the approximate amount of time spent consulting for a fee the last four years

Current year                     %     Last Year                  %       Previous Year     %

·        Number of years, prior to the last four, that you were engaged in consulting                     years

During this time, approximate percentage of time spent consulting for a fee.               %

·        Describe your field consultation specialty during the last four years:                                                                                                                                                                                

·       

 

In addition to a consulting fee, do you receive other income related directly, or indirectly, to your consulting service, such as product sales?          Yes  /   No

·        If yes, how do you prevent such income from conflicting with your services as an independent consultant?                                                                                                                                                                                                                                                  

·        List the names and complete mailing address of three clients you have served during the past four years.  

If the work was for a company, list the name of the individual for whom you worked.

Name                       Company                            City               State             Phone 

                                                                                                                                                             

Previous Work Experience

Briefly list work experience since graduation, or during last 15 years:

Employer Name         Address                              Duties                                          Duration

                                                                                                                                            

Professional Associations

List professional organizations in which you are active or hold a membership:

                                                                                                                                   

Laboratory Services

If you operate a laboratory, please explain facilities and services offered:

                                                                                                                                 

Current Job Duties

Explain Services offered, products produced, etc. of your company, and your responsibilities within the company:                                                                                                                                                                                                                                                                               

I CERTIFY THAT ALL ABOVE INFORMATION IS ACCURATE TO THE BEST OF MY KNOWLEDGE AND I AGREE TO COMPLY WITH THE CODE OF ETHICS FOR THE IOWA INDEPENDENT CROP CONSULTANTS ASSOCIATION.

                                                                                                                        

Signature                                                                    Date

I have enclosed my  $                membership fee.

Send completed application to:

Kirk Leeds, Executive Director, IICCA

4536 114th Street

Urbandale, Iowa 50322

515/727-0648 or 515/251-8657

e-mail: kleeds@associationinsight.com