International Pest Control Association

Please provide the following information, then press the PRINT button at the base of this form. You may then either MAIL or FAX the completed form (and supporting documents) to:

International Pest Control Association
PO Box 6356
Blacktown NSW 2148
Australia

Facsimile: 02 9831 8759 (International: +61 2 9831 8759)

Your Name:
Position:
Company:
Street Address:
Address (cont.):
City:
State/Province:
Postal/Zip Code:
Country:
Work Phone:
FAX:
E-mail:
URL:

Pest Control Licence Number:
Company Pest Control Licence Number:
Other Licence numbers and types:
Have you been convicted of any offence in relation to your work as a pest controller?	Yes No
Choose one of the following membership options (all figures quoted are renewable per annum):	$350 AU yearly for Affiliate Membership $350 AU yearly - 1-5 employees $950 AU yearly - 6-15 employees $1,500 AU yearly - over 15 employees
Public Liability Cover:
Public Liability Insurer Details:
Public Liability Expiry Date:
Professional Indemnity:
Professional Indemnity Insurer Details:
Professional Indemnity Expiry Date

I/We confirm all of the above information is true and correct and I/We agree to abide by the Code of Ethics of the International Pest Control Association. I/we have also read the Terms and Conditions and agree to these terms.	Yes
Have you included a copy of your accreditation certificate and/or Pest Control Licence?	Yes

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