ALSTAR Organization Application

Organization

Name:

Division:

Address:

Address 2:

City:

State (2 Character Code):

Postal Code:

Country:

Max Products Registered per State:

Purchase Order:

Administrator (Organization's primary ALSTAR contact)

First Name:

Last Name:

Phone:

Mobile Phone:

Email Address:

Billing Contact (authorizes payment)

First Name:

Last Name:

Phone:

Mobile Phone:

Email Address:

Billing Address

Billing Address:

Billing Address 2:

Billing City:

Billing State (2 Character Code):

Postal Code:

Country:

Accounts Payable Contact (receives invoice and remits payment)

First Name:

Last Name:

Phone:

Mobile Phone:

Email Address:

By submitting this application, I acknowledge that I have reviewed the current ALSTAR subscription rates and authorize payment of charges incurred. I have also reviewed the ALSTAR Participation Standards and agree to abide by the standards. I understand that ALSTAR information is the intellectual property of CERIS and Purdue University. I agree that I will not reformat, reuse, or redistribute any ALSTAR information for commercial use, paid or otherwise without prior, written permission from the National Pesticide Information Retrieval System at CERIS.

Requestor

Name:

Email Address: