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MEMBERSHIP TYPE2013 APPLICATION FOR MEMBERSHIPActive-North American, Supplemental, Franchisor-Parent Company,Franchisee-Independent Private BusinessPART ONE: APPLICANT INFORMATIONPlease select the type of company membership you are applying for by checking the appropriate box below.Active-North AmericanSupplementalOwners, corporate officers or their designated representatives of companies located in the US, Canada and Mexico, who actively engage in providingcommercial kitchen exhaust cleaning services may apply for Active Membership on behalf of the company. Active members shall be entitled to all rights andprivileges of membership, and shall maintain one (1) vote at all official meetings of the Association.A subsidiary or branch office of an Active Member, which is also engaged in providing commercial kitchen exhaust cleaning services. Independent franchiseeoperations shall not qualify for Supplemental Membership. Supplemental Members shall receive the same benefits and opportunities as ActiveMembers, but shall not have voting rights or be entitled to hold elective office within the Association. Companies eligible for Supplemental Membership maynot apply for Active Membership.Annual Dues$880.00$715.00Non-Refundable Application Fee $250.00MEMBER INFORMATION (please print clearly)Company NameMain AddressCityZip or Postal CodeState/ProvinceCountryBilling Address(if different than mailing address)CityZip or Postal CodeState/ProvinceCountryWhich address is the primary address to be listed in the online member directory? 0 Main 0 BillingTelephoneFaxWebsiteNumber of years in businessNumber of locationsNumber of FullTime EmployeesType of business 0 Private or Public Independent 0 Subsidiary or Branch Location 0 Franchisor 0 FranchiseePrimary Contactall invoices and official notificationswill be sent to this personFirst/Last:Title:Email:Secondary ContactFirst/Last:Title:Email:COMPANY BACKGROUND INFORMATIONIKECA reserves the right, in its sole discretion, to deny an application based on responses to these background questions.Answers to the following questions are mandatory. Failure to respond to each question will result in the application being returned. Failure to provide accurate, true and correct information shall constitute grounds fordenial of your membership application, or termination of your membership. If the applicant answers “Yes” to any of questions 1-4 it must submit the following before its application will be considered:1) A complete written explanation of the circumstances surrounding the proceedings, including a narrative describing where the incident occurred, the date of the incident; and the outcome of the proceedings.2) Copies of relevant court documents.HAS THE APPLICANT:1. Ever violated or infringed upon any IKECA intellectual property, including but not limited to, IKECA trademarks? YES NO2. Ever been deemed or found to be in noncompliance with any state, local or federal law? YES NO3. Ever failed to obtain a license or authorization needed to conduct its business? YES NO4. Been a defendant in civil litigation in which the basis of the complaint against the applicant alleged negligence, malpractice, lack of professional conduct or fraud? YES NO5. Is the company located at the exact address provided on the application? If not, please explain the discrepancy. YES NO6. Please provide the name and address of the Authority Having Jurisdiction (AHJ)/Fire Authority closest to the address listed on this application.
CERTIFICATION APPLICANT INFORMATIONApplicant Name2013 APPLICATION FOR MEMBERSHIPActive-North American, Supplemental, Franchisor-Parent Company,Franchisee-Independent Private BusinessPART TWO: CECS CERTIFICATIONCandidate’s affiliation withapplicant companyDate of your examLocation of ExamOwner Manager Employee Other:Note: Exams scheduled within 15 business days of applicationsubmission will be subject to a $100 rush fee.PRIVATE PROCTOR INFORMATION (Only completed if you are requesting a privately proctored exam.)In order to set up a privately proctored IKECA exam, you must find a qualified proctor to administer the exam. You will need to contact the proctor to arrange an appointment totake the exam that is convenient for both of you. Three hours are allowed for the CECS exam. The proctor should be a disinterested, third-party, and cannot be a direct supervisorof anyone taking the exam. The exam packet will be sent to the proctor, with a prepaid return envelope, and returned by the proctor. Both the examinee and proctor will needto sign an affidavit verifying that exam procedures were followed.Proctor NameCompany NameStreet AddressCityZip or Postal CodeTelephoneEmailDeadline:State/ProvinceCountryCertification Applications are due 15 business days prior to the test date. Exams scheduled earlier are subject to a$300 rush fee.FaxCancellation Policy:Refund Policies:ADA COMPLIANCEAll exam cancellations must be received in writing no less than 10 business days in advance of the test date.No refunds shall be provided for exams; however, examination fees may be applied toward taking the exam at afuture administration of the exam.The IKECA Certification Examination shall be administered in accordance with the requirements set forth in theAmericans with Disabilities Act (ADA). If you require special assistance or unique conditions in taking the IKECACertification Examination as a result of a disability or physical impairment, please contact IKECA Headquarters formore information.100 North 20th Street, Suite 400 • Philadelphia, PA 19103 • 215-320-3876 • fax 215-564-2175 • www. ikeca.org
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