CROP CONSULTANTS AUSTRALIA INCORPORATED MEMBERSHIP APPLICATION FORM CCA operates under the provisions of the Associations Incorporation Act 2009 (NSW) FIRST NAME: SURNAME: YEAR BORN: BUSINESS/COMPANY NAME: CURRENT POSITION: POSTAL ADDRESS: MOBILE: WORK TELEPHONE: EMAIL: TERTIARY QUALIFICATIONS: FAX: OTHER RELEVANT INFORMATION: CROPS OF INTEREST: (please circle) Cotton Grains Pulse Oilseeds Other……………………………. MAIN BUSINESS ACTIVITY: (please circle) Reseller Corporate Research Independent Consultant Other:…………………………………………………….. Has an existing CCA member encouraged you to become a member? (please provide their name) REASON FOR JOINING CCA: HAVE YOU BEEN A MEMBER OF CCA PREVIOUSLY? Yes No Declaration IMPORTANT! Please ensure you complete this Declaration YEARS IN INDUSTRY: I hereby apply for membership of Crop Consultants Australia Incorporated (CCA) on the basis of the information provided on this form and agree to accept the decision of my eligibility to an appropriate category of membership. I agree to abide by the Association’s constitution, including the payment of membership fees, and also to abide by the Code of Conduct. MEMBERSHIP CATEGORY (select one) Anyone having given false information in order to obtain membership (or upgrade their membership status) or is deemed to have willfully acted in a manner prejudicial to the interests of the association may be liable for suspension or expulsion. SIGNATURE: DATE: / Industry Member Young Professional Consultant Professional Consultant Student Member Life Member If you selected a ‘professional’ category, do you spend more than 16hrs per working week (on average) providing agronomic advice? / Yes No NOMINATOR: I,………………………………………….(name of current member) nominate the applicant for membership. ……………………………………….. Signature of current member ……/……/…… Return completed form to: Crop Consultants Australia Incorporated PO Box 349, Woombye QLD 4559 Fax: 07 3036 6357 E: info@cropconsultants.com.au Mob: 0429 925 459 ABN: 77 618 159 986 www.cropconsultants.com.au An invoice will be sent upon approval of your membership by the CCA Board. The CCA Office is able to coordinate the signature at the bottom section of this form if necessary.