Business Associate Application Form2009

JG&G Consulting Services Inc.

Associate Application
Any changes to Form will automatically disqualify application

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Applicant Information

* Preferred Salutation: / Mr. Miss. Ms. Mrs. Dr. Other
* Gender: / Male Female
* Surname: / * Given Names:
* Country: / * Title:
* Business Address: / * City:
* Province: / * Postal Code:
* Business Telephone: / ext
eg.999-999-9999 / Alternate Telephone: /
eg.999-999-9999
# of CMC/PRINCE2/PMP/CBAP/ITIL
Certified in your firm: / 1 2 -10 11 - 25 26 - 50 51+
* E-mail address #1: / E-mail address #2:
Website Address: /
/ * Address Correspondence to: / Residence
Business

Residence Information

* Residence Address: / * City:
* Province: / * Postal Code:
* Residence Telephone: /
eg.999-999-9999 / Mobile Telephone: /
eg.999-999-9999

Areas of Preferred Practice

Select the areas of business management in which you have professional interest and experience.

Operations Management / Human Resource Management / Strategic Management
PMO / Information Management / Project Management
Organizational Change Management ITIL - Please specify:
Other - Please specify:

Certification Requirements

Degree(s) Conferred

By submitting this application, I acknowledge my commitment to pursue the JG&G Consulting Services Inc.’ Certification

* I have an undergraduate or graduate degree or CA, CGA, CMA, (or International Equivalent) CMC, CBAP, PgMP, PMP, ITIL Expert, PRINCE2, or a PhD.
Please attach university/degree transcripts or proof of designation. / Yes No
Institute / Degree/Designations / From: Month/Year / To: Month/Year
1.
2.
3.
Transcript File – If you have more, please include in e-mail.
(PDF and DOC extensions accepted, maximum 2MB)

Designations(s) and other Memberships

Association/Institute / Designation Earned / From: Month/Year / To: Month/Year

Consulting and Other Business Experience

Please attach a current Curriculum Vitae (CV) and resume.

Name and Address of Employer / Nature of Business / Position / From: Month/Year / To: Month/Year
Curriculum Vitae (Maximum 2MB) / Please attach in e-mail to
Resume (Maximum 2MB) / Please attach in e-mail to
Applicants with 10 years or more relevant consulting and/or project management and/or ITIL experience may be qualified for the Experienced Path.
* I would like to be considered for this Path / Yes No
Date consulting since: / Date of Birth:
*For statistical purposes only

Sponsors

Sponsors must be Certified Management Consultants (CMCs), Certified Program and/or Project Management professionals (PgMP, PMP, PRINCE2), and/or Certified Business Analysts (CBAPs), and/or Certified ITIL Expert (Certified ITIL Service Delivery v2 or v3). They attest to the accuracy of the information on the application form and implicitly recommend acceptance of the applicant as a member of JG&G Consulting Services Inc.

Name:
Phone: /
eg.999-999-9999 / Email:
Business Address:
Knowledge of Applicant: / Professional Other / Years:
Name:
Phone: /
eg.999-999-9999 / Email:
Business Address:
Knowledge of Applicant: / Professional Other / Years:

Privacy

Pursuant to PIPEDA (Personal Information and Electronic Documents Act), JG&G Consulting Services Inc. collects the personal information contained in this form solely for administrative purposes related to this application and at no time discloses information to unauthorized parties.

Your contact information will remain on a secure internal database. From time to time JG&G Consulting Services Inc. offers a number of services to members, some of which require your explicit permission. If you do not wish your personal information used for the following purposes, please check the appropriate boxes:

I do not wish to have my contact information listed on the searchable website.
I do not wish to receive information from JG&G Consulting Services Inc. service partners (i.e. information on new services and discounted services)
I do not wish to receive information from JG&G Consulting Services Inc. (includes event notification)

Please note, you may change this at any time by contacting JG&G Consulting Services Inc. directly. Questions, concerns or complaints regarding the collection of personal information should be directed to the Privacy Officer, JG&G Consulting Services Inc., 15 Maitland Place, Suite 1006, Toronto, ON M4Y 2X3 or .

Declaration

I, , hereby declare that I have been working as a management consultant and/or project manager since , and during that time I have devoted at least two-thirds of my working time solely to the professional practice of management consulting and project management. I have read JG&G Consulting Services Inc.'s Code of Professional Conduct, understand it, and agree to abide by it. I have reviewed JG&G's Privacy Policy and have marked the appropriate boxes to ensure JG&G Consulting Services Inc. is aware of any concerns with privacy.
I have read the above statement and declare that all information is accurate to the best of my ability.

Membership Fees and Fee Schedule

Level 1 Membership fees are $39.95 USD a month, or $399 USD (+ GST - Canadians only) per year (includes the last 2 months free). If you have attended the mandatory orientation session, you receive a $150 USD Discount after the first year towards the following year’s membership dues (12 months of paid dues). If you attend the orientation session within 6 months of membership, the discount will apply.

Level 2 Membership fees are $29.95 USD a month, or $299 USD (+ GST - Canadians only) per year (includes the last 2 months free). If you have attended the mandatory orientation session, you receive a $100 USD Discount after the first year towards the following year’s membership dues (12 months of paid dues). If you attend the orientation session within 6 months of membership, the discount will apply.

Level 3 Membership fees are $19.95 USD a month, or $199 USD (+GST – Canadians only) per year (includes the last 2 months). If you have attended the orientation session, you receive a $50 USD Discount after the first year towards the following year’s membership dues (12 months of paid dues). If you attend the orientation session within 6 months of membership, the discount will apply.

You must pay on-line at . Your credit card or bank account will be charged upon submitting this application. You will receive a receipt and copy of your application via e-mail. You will be notified once your application has been processed. Membership dues cannot be invoiced. GST# 83882 9547 RT

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