Request for Certification Evaluation Application

NESDCA uses the information in this application to determine your qualifications for evaluation and to ensure that NESDCA will contain a fair balance of interests. NESDCA will not use this information for any other purpose than the above. Please provide us with as much information as you feel will assist us in the APPROVAL process. NOTE: AN EVALUATOR WILL CONTACT YOU REGARDING AVAILABLE DATES.

 
Name of Individual
Title
Employer
Mailing Address
 
City
State/Province
Country
Zip/Postal Code
Telephone
Fax
Email Address
FEE: There is no fee to be evaluated for certification. (Travel expenses will be required if requested other than NESDCA scheduled evaluation/certification events) SEE "FEES" UNDER CERTIFICATION RULES.
Please indicate Scent, team is requesting to be evaluated for:
 

Termite
Bedbug
Carpenter Ant
Other (Please indicate below)

1. EVALUATION

a. Provide the name and location of the training facility from which you and your canine were trained. Please include experience and time handling Scent Detection Canine.

b. Please provide information about the facility to be used for certification. Include name, address, website (if available), also include type of building, hotel, office bldg. etc.
c. Are you willing to abide by, support, and promote NESDCA, our By-Laws and mission of Entomology Scent Detection? YES         NO

2. REPRESENTATION

Indicate below the name of the business you would be representing:

3. Funding Source(s) for your Participation
a. Please provide a business address, telephone number, along with a specific contact person and their mailing address, e-mail, and telephone number.
4. ADDITIONAL COMMENTS

If granted NESDCA Certified Entomology Scent Detection Canine Team status, I agree to abide by the RULES and BY-LAWS NESDCA and agree to notify the Secretary of the NESDCA of a change in status, including change of employment, organization represented, location or funding source.

I attest that all of the information on this application is true and accurate.
Type your FULL NAME
Today's Date