Membership Application Please note required fields are marked with an asterisk(*).Name* Prefix Mr.Mrs.MissMs.Dr.Prof.Rev. First * Middle Last * Suffix First and Last name are requiredWork Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Address Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Preferred Mailing Address* Work Home County of Residence* Work PhoneHome PhoneCell PhoneFaxEmail Address* Would you like to be added to the NCPC Emergency Information contact list?* Yes No If yes, provide a valid cell # and email address above.Check All That Apply* Producer Employee of Contract Grower Employee of Production Company/Integrator Allied (Any individual, partnership, firm or corporation who is involved in a company or industry that is allied through commerce or otherwise supportive of pork production in North Carolina.) Other ProducerContracting Or Independent? Contracting Independent (including Genetics/SS, or Weaner/Feeder Pig Producers) ContractingContract with* Farm Name* Job Title* Are you the primary contact for a permitted farm?* Yes No Farm Permit # IndependentFarm Name* Job Title* Are you the primary contact for a permitted farm?* Yes No Farm Permit # Employee of Contract GrowerEmployer* Job Title* Farm Name* Employee of Production Company/IntegratorEmployer* Job Title* AlliedAffiliation* (Examples include Animal Health, Financial Services, Equipment, Feed, Pharmaceutical, etc.)Employer* Job Title* OtherEmployer* Job Title* How are you related to the pork industry?* Why do you want to be a member of the NC Pork Council?*Membership AgreementMembership is based on NC Pork Council Board approval.Check All That Apply I want to be a member of the NC Pork Council. I want to receive the quarterly magazine, "The Pork Report" by mail. I want to receive the quarterly magazine, "The Pork Report" in digital format. I want to receive the electronic newsletter, "The Porkline", as well as other NCPC electronic communications.
