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1. Member Information

Application type
New Application Renewal

Member First Name:

Member Last Name:

Organization Name:

Organization Type:
Proprietorship Partnership Corporation LLC

Date Established:

County:

Street Address:

City:

State:

Zip:

Phone:

Cell Phone:

Fax Number:

Email:

Company Web Address:

Is the Member a Professional Engineer?
Yes No

Does the Member have a PE license?
Yes No

Is the Member a consultant?
Yes No

*This is the name that will display as insured on your quote. Do not enter “Me” or “No Name” if you are a sole proprietor.

2. Membership Affiliation

Membership is required to obtain coverage. Are you a member of ACS or AACT?

ACS AACT

Member #:

3. Personnel - Number of Staff

Principals / Partners / Directors:

Last Year:

This Year:

Other Licensed Professionals:

Last Year:

This Year:

Other Staff:

Last Year:

This Year:

4. Gross Billings

Total Gross Billings for professional services (collected or not) to include reimbursable expenses and sub-consulting fees:

Current Year (estimated):

Prior Year (actual):

Next Year (projected):

Work pursuant to Federal or State grants		%
Feasibility Studies		%
Patent Research		%
All Other Billings		%
Total (Must equal 100%)	100%

Please indicate percentage of the Member’s gross billings derived from projects outside the USA and Canada:

5. Professional Disciplines

Please provide a summary description of professional services the Member is engaged in:

Is the Member working with or planning to work with any ethanol and/or ethanol related projects?
Yes No

Do you engage in any laboratory testing?
Yes No

Specify a percentage of the Member’s Gross Billings (Total must equal 100%):

DESCRIPTION	PERCENTAGE	YEARS EXPERIENCE
Aerospace / Transportation
Agriculture & Food
Analytical
Biochemistry
Biotechnology
Chemical Education
Chemical Information
Clinical / Diagnostic
Colloids & Surfaces
Combination Chemistry
Computing / Molecular Modeling
Electronics / Semiconductors
Energy / Fuels
Environmental – Analyzing
Environmental – Remediation
Expert Witness
Forensics
Geochemistry
Glass / Ceramics / Composites
Health & Safety
Inorganic Chemistry
Lubricants / Oils (Petrol)
Marketing / Sales / Business

DESCRIPTION	PERCENTAGE	YEARS EXPERIENCE
Metals / Metal Products
Nuclear
Organic
Paint / Coatings
Patent Research
Personal Care / Cosmetics
Pharmaceutical / Medicinal
Physical
Pollution – Analysis
Pollution – Remediation
Polymers / Plastics
Process Engineering / Modeling
Pulp / Paper / Wood
Rubber
Soaps / Detergents / Cleaners – Process
Soaps / Detergents / Cleaners – Analysis
Soaps / Detergents / Cleaners – Research
Textiles / Fiber
Toxicology
Writing – Technical
Writing – Reporting
Other (please specify):
Materials
Total (Must equal 100%)		100%

Please describe the Member’s largest projects during the past 3 years.

CLIENT NAME	SERVICE	MEMBER’S FEE	TOTAL PROJECT COST

Do you use a written contract with clients?
Yes No

Do you limit your liability in contract?
Yes No

6. Subcontractors/Subconsulants

Please indicate percentages of work Member subcontracts to others:

Are written contracts used for all subcontractors and subconsultants?
Yes No

Do the Member’s contract with subcontractors and subconsultants contain indemnification and hold harmless provisions?
Yes No

Does the Member obtain certificates of insurance from all subcontractors and subconsultants?
Yes No

Is the Member named as an Additional Insured under all subcontractor and subconsultant General Liability policies?
Yes No

7. Management

Does the Member have any in-house quality control procedures?
Yes No

Has the name of the Member changed or has any other firm been merged with or into the Member, or is any such change pending?
Yes No