NAICC Leadership Program

Application
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Date*
MM slash DD slash YYYY
Professional Specialization: (check all that apply)*
- Crop Consultant
- Quality Assurance
- Research Consultant
Name*
First Last
Company
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone (Business)
Phone (Mobile)
Phone (Fax)
Email*
Member of NAICC Since*
Personal Information
Date of Birth*
MM slash DD slash YYYY
Gender*
- Male
- Female
Spouse’s Name (if applicable)
Education
Please list highest level of education achieved
Name of School*
Date of Graduation*
MM slash DD slash YYYY
Diploma/Degree*
Major*
Minor (if applicable)
Employment
Are you self-employed?*
- Yes
- No
If you work for a company, what is your position?
Name of Immediate Supervisor
Please list work experience since high school*
Please list all state(s) in which you consult/work:*
Please list the crops for which you consult*
Professionalism
List any NAICC leadership activities in which you are/were involved
List any professional organizations of which you are a member
List any community services/activities in which you are involved
List any honors you have received personally and professionally
Essay
In 250 words or less, please tell us why you are interested in the NAICCLP and how you would expect to use the knowledge and experience gained. You may also attach your essay to this application.
Essay Upload
Max. file size: 256 MB.
Acknowledgments
Emphasis on Safety

We are serious about safety. We expect you to be serious about safety also by following the instructions of various tour guides and hosts, by acting prudently, and by using good judgment. NAICCLP offers a wide array of exciting learning opportunities. However, participation does carry a degree of risk and personal responsibility. It is important to read and understand the following caveats.

Although the National Alliance of Independent Crop Consultants (NAICC) has taken precautions to ensure an enjoyable, educational, and safe experience, it is impossible to guarantee absolute safety. There is inherent risk in travel. Conditions at various tour destinations and actions of other parties, such as drivers, event holders, sponsors, and organizers, are beyond our control. By signing below, you acknowledge that the National Alliance of Independent Crop Consultants (NAICC) affiliates are not responsible for the errors, omissions, acts, or failure to act of any party or entity conducting a specific event, tour, or activity as part of this program.

Emergency Medical

By signing below, you authorize the National Alliance of Independent Crop Consultants (NAICC) or its authorized designee to obtain emergency medical treatment for you, if needed, as may be deemed advisable. You understand that the NAICC does not provide health insurance for you and that you should carry your own health insurance. You will be financially responsible for any costs of such treatment. Further, by signing you certify that you are physically fit and sufficiently prepared to participate and that you are not disobeying instructions from a qualified medical professional who advises against your participation.

The Legal Stuff: Waiver & Release of Liability

In consideration for being allowed to participate in the NAICC Leadership Program, you assume responsibility for your own safety and needs and for all of its potential risks. Participation in this program is strictly voluntary, and by signing you acknowledge that you freely choose to participate.

With the intention of being legally bound by this document, the undersigned hereby releases from liability and agrees to indemnify and hold harmless the National Alliance of Independent Crop Consultants (NAICC) and any of its employees, contractors, volunteers, or agents representing National Alliance of Independent Crop Consultants (NAICC). This release is for any and all liability for personal injuries (including death), disability, property losses or damages, property theft, or actions of any kind which may occur as occasioned by or in connection with traveling, activities, or accommodations relating to this program. The undersigned hereby forever acquits and discharges the National Alliance of Independent Crop Consultants (NAICC) and any of its employees, contractors, volunteers, agents, or affiliates of and from any and all actions, claims, causes of actions, loss of services, loss of earnings, costs, demands or damages, on account of or in any way arising out of any and all known and unknown causes which may occur with the aforementioned. By signing, you understand that this document is written to be construed broadly to the maximum extent permissible under applicable law. If any portion is held invalid or unenforceable, then you agree to be bound by the remaining terms.

I CERTIFY THAT I HAVE READ THIS DOCUMENT. I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND IS LEGALLY BINDING UPON ME, MY AGENTS, AND HEIRS. I SIGN IT OF MY OWN FREE WILL.
You must agree to continue*
- I agree
Participation Commitment
Participation Fee Payment – Please indicate how you will handle the participation fee*
- I will personally pay the full amount
- My employer/sponsor will pay the full amount
- My employer/sponsor will pay a partial amount, and I will be responsible for the balance
- I would like information on scholarship assistance
If employer/sponsor is paying part of or the entire fee, please complete the section below
Amount to be paid by employer/sponsor*
Name of employer/sponsor*
Title First Last
Employer/Sponsor mailing address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
All participants are required to attend ALL program sessions in their entirety. Refunds will not be given if participant does not fulfill these requirements.
FOR APPLICANTS WHO ARE NOT SELF-EMPLOYED please complete the following section.

If you are selected to participate in the National Alliance of Independent Crop Consultants Leadership Program, your employer must agree to provide time away from work for you to attend all required activities of this program as well as any expenses not covered by the applicant or NAICC.

We will contact your employer to obtain their agreement.
Employer Contact Info
Spouse Commitment
Spouses are an important part of this program and need to be knowledgeable about the program and the time commitments. We ask spouses to make a commitment as well by acknowledging their willingness to support your participation in this program. As a way of showing our appreciation, we will extend to them complementary spouse registration to the NAICC Annual Meeting.

We will contact your spouse to obtain their agreement.
Spouse Contact Information
Participant Commitment
I attest to everything stated in my application is true and complete.

I have read all of the information in the National Alliance of Independent Crop Consultant Leadership Program Information and Application packet indicating the requirements for participation in the program and agree to all responsibilities outlined within. I also agree to commit the time and resources necessary to attend all functions.

I also agree to the release NAICC, its staff and Executive Board members of liability as outlined on the Acknowledgement page.
You must agree to submit this form
- I agree