First Name
Last Name
Position
Email Phone Fax
Street Address Residence Business
City State Zip
If applicable, organization representative you will replace
Voting privilege requested Voting Non-Voting
Voting classification requested - select one Association Distributor General Interest Producer User
Principle product or service offered by your organization
Technical background (attach resume or relevant document indicating interests)
Particular committee preference, if any Committees: A.1 -Specifications A.2 -Research A.3 -Membership and Funding A.4 -Education A.5 -Organization Liaison B. -Editorial
Does your organization have laboratory facilities or other resources that might be available for Cooperative Council activities? Yes No
Will applicant contribute to the work of the Council by attending meetings regularly and/or by correspondence and response to letter ballots? Yes No
Comments, if any
Date