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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Address Street Address City State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Preferred Mailing Address*WorkHomeCounty of Residence*Work PhoneHome PhoneCell PhoneFaxEmail Address* 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?ContractingIndependent (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.
