IAPMO uses the information in this application to determine your qualifications and to assure that IAPMO technical committee appointments are made in a way that ensures that committees will contain a fair balance of interests. Instructions for completing this form:

1. Read each section carefully before completing.
2. Tab through to get to a new section of the form.
3. Fill in the form completely. DO NOT LEAVE BLANK SPACES. If a section does not apply to you, indicate "N/A" (not applicable) or, if you need more room than is allowed, you may attach a separate sheet of explanation as a "Word" document or in PDF format.
4. If you are applying as a representative to an organization, you will need to supply a letter of authorization. It must be submitted on the organization's letterhead and signed by an officer of the organization. You may fax this document to IAPMO at 909-472-4246, or you may mail it to IAPMO Code Development, 4755 E. Philadelphia Street, Ontario, CA 91761-2816. Your fax cover sheet/transmittal sheet should indicate that you are/have submitted your application online, including the date submitted. This letter may also include information requested in Section 3.5.6. The following is a SAMPLE of suggested wording for the authorization letter.

SAMPLE: We, (organization’s name), authorize (your name) as our representative to serve on the technical committee. We will support (your name) for his/her time and travel expenses during his/her service as a member of the technical committee.

5. Review the form for accuracy before submitting to IAPMO.

Please contact IAPMO by phone at 800-854-2766, or by e-mail at codesdept@iapmo.org if you have any questions about this form.

1. QUALIFICATIONS OF APPLICANT
a. Attach separate statement resumé providing evidence of your general knowledge and competence in the scope (work) of the committee.

b. What is your specific relationship to one or more elements of the scope of the committee?

c. Will you be able to actively participate in the work of the committee including responding to correspondence and attending committee meetings?

2. REPRESENTATION
Indicate below the name of the entity you would be representing and include written authorization from that entity authorizing you to be their representative:

a. Does the organization you would represent have a mechanism for instructing votes? If so, can the time constraints imposed by the Regulations Governing Consensus Development be met?

3. FUNDING SOURCE(S) FOR YOUR PARTICIPATION
a. What person(s) or organization(s) would fund your participation as a committee member, either in whole or in part? (You should list your employer if your participation is funded by your employer or if your participation is part of your employment responsibilities or otherwise related to your employment.)

b. Background and description of your employer and/or other person(s) or organization(s) funding participation:

4. ADDITIONAL COMMENTS

Languages, other than English:

INTEREST CATEGORIES

(a) Manufacturer. A representative of a maker or marketer of a product, assembly or system, or portion thereof that is affected by the standard.
(b) User. A representative of an entity that is subject to the provisions of the Document or that voluntarily uses the Document.
(c) Installer/Maintainer. A representative of an entity that is in the business of installing or maintaining a product, assembly, or system affected by the standard.
(d) Labor. A labor representative or employee concerned with safety in the workplace within the scope of the standard.
(e) Research/Standards/Testing Laboratory. A representative of an independent research organization; an organization that develops codes, standards and other similar documents; or an independent testing laboratory.
(f) Enforcing Authority. A representative of an agency or an organization that promulgates or enforces the standard.
(g) Consumer. A person who is or represents the ultimate purchaser of a product, system or service affected by the standard but who is not a User as defined in Section 3.5.6.2.
(h) Special Expert. A person not representing as defined in Section 3.5.6.1 through Section 3.5.6.7 and who has special expertise in the scope of the standard or portion thereof.

COMPLETE A SEPARATE APPLICATION FORM FOR EACH COMMITTEE ON WHICH YOU DESIRE TO SERVE. IN ORDER TO ASSURE THE PROMPT PROCESSING OF YOUR REQUEST, PLEASE BE SURE TO COMPLETE ALL QUESTIONS AND SIGN THIS APPLICATION.

If appointed, I agree to abide by the rules and guidelines of IAPMO. In addition, I hereby agree to notify the Secretariat of the IAPMO Executive Committee of a change in status, including change of employment, organization represented, or funding source. I also agree that IAPMO shall have, and I hereby grant, all and full rights in copyright in any material that I author, either individually or with others, as a member of this committee, or that I submit for the proposed use of the committee in an IAPMO code or standard or other IAPMO document. I further acknowledge that I acquire no rights in any publication of IAPMO and that copyright and all rights in all materials produced by IAPMO technical committees are owned by IAPMO and that IAPMO may register copyright in its own name.

I do not now hold and I do not intend to hold any patent, the use of which would be required for compliance with any material that I author – either individually or with others – as a member of this committee, or that I submit for the proposed use of the committee in an IAPMO code or standard or other IAPMO document.

I attest that all of the information on this application is true and accurate.

Date: 5/18/2012

Signature

Your typed name above constitutes your electronic signature.