GEORGIA ASSOCIATION OF PROFESSIONAL AGRICULTURAL CONSULTANTS

MEMBERSHIP APPLICATION FORM

Georgia Association of Professional Agricultural Consultants

Please print and complete this form and return it to the Membership Chairman at the address given at the end of this form.

For category descriptions and qualifications, please refer to attached

GAPAC Constitution.

Applicants for Student or Retired categories complete section A only.

Full, Associate, and Provisional applicants complete sections A & B.

SECTION A

APPLYING FOR: _____Provisional _____Full _____Associate _____Student _____Retired

Name: ______________________________________________________________________

Company: ___________________________________________________________________

Title: _______________________________________________________________________

Address: ____________________________________________________________________

City: _________________________ State: ____________ Zip Code: _________________

Business #:____________________________ Home #: ______________________________

Fax #: _______________________________ Mobile #: _____________________________

E-Mail Address: ______________________________________________________________

____________________________________________________________________________

SECTION B

Are you a member of another state’s crop consultant’s association? _____Yes _____No

If Yes, what state? _____________________

GA Dept. of Agriculture Commercial Pesticide Applicators License #: _____________________

EDUCATION:

DATE

COLLEGE OR UNIVERSITY MAJOR DEGREE RECEIVED

______________________________________________________________________________

EXPERIENCE: List briefly your work experience since graduation from college or during the past ten years. Attach additional sheets if more space is needed.

POSITION LENGTH OF

EMPLOYER-NAME & ADDRESS DESCRIPTION SERVICE

______________________________________________________________________________

INDEPENDENT CONSULTING EXPERIENCE:

1. Date on which independent crop consulting for a fee was first performed:

______________________________________________________________________

2. Please indicate the approximate amount of time spent consulting for a fee during the last four

years:

Current year: ______% Last year: _______% Previous years: _______%

3. Number of years prior to the last four years that you were engaged in consulting activities:

______________________________________________________________________

4. Describe your field of consultation or specialty during the last four years. Include your crops

consulted and services provided.

______________________________________________________________________________

5. a) Do you provide technical data and/or recommendations to clients on a fee basis?

__________YES ___________NO

b) Are your fees itemized and billed to the client? _________YES __________NO

c) Do you currently receive any compensation from a client’s purchase and/or application of

products* based on your recommendation or data?

_________YES ___________NO

*Definition of Products:

1. Inorganic or organic soil amendments

2. Seed or plant materials

3. Commercially available equipment, machinery, or implements

4. Chemical or biological pest-control inputs

5. Animal feed or medicinal products

d) If you are employed by a company, is your compensation supplemented or subsidized by

income derived from the sale and/or application of products as defined above?

_________YES __________NO

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 request more detailed information, please indicate. _________Yes, I am uncertain of my eligibility.

REFERENCES:

Please give the names and addresses of five of your clients. If work was for a company, give the name of the individual who contracted the work. Please fill in completely. These references should be able to verify the information you provided above.

City/

Name Company Address State Phone

1. ___________________________________________________________________________

2. ___________________________________________________________________________

3. ___________________________________________________________________________

4. ___________________________________________________________________________

5. ___________________________________________________________________________

List professional registries and associations in which you are active or hold membership.

_____________________________________________________________________________

ACKNOWLEDGEMENT & SIGNATURE:

I certify that all preceding information is accurate to the best of my knowledge. I have read, I understand, and I agree to comply with the Bylaws and Code of Ethics for the Georgia Association of Professional Agricultural Consultants.

Signed: ____________________________________________ Date: __________________

GAPAC Sponsor: ___________________________________ Date: __________________

RETURN COMPLETED APPLICATION TO:

GAPAC Membership Committee Chairperson

Jack Royal

Rt. 1 Box 37

Leary, GA 39862

229-792-6506
jroyal@aol.com

Revised: February 15, 2004