| KAM Designation Application |
Please note that online payments are not yet available. KAM accepts purchase orders and checks.
(*) Indicates Required Fields |
| Contact Information |
| *First Name: |
*Last Name: |
| *Title: |
| *Organization: |
| *Address: |
| *City: *State: *Zip: |
| *Business Phone: |
*Email: |
| *Designation Type: Kansas Mapper (KM) Professional Kansas Mapper (PKM) Kansas GIS Professional (KGISP) |
| Employment History |
| *Current/Most Recent Employer: |
*Employment Period: From: To: |
| *Address: |
*City: *State: *Zip: |
| *Type of Business: |
*Your Position/Title: |
*Please list your principle duties:
|
| Other Mapping Related Employment: |
Employment Period: From: To: |
| Address: |
City: State: Zip: |
| Type of Business: |
Your Position/Title: |
Please list your principle duties:
|
| Other Mapping Related Employment: |
Employment Period: From: To: |
| Address: |
City: State: Zip: |
| Type of Business: |
Your Position/Title: |
Please list your principle duties:
|
| Education |
| *High School Graduate/GED: Yes No |
Year Graduated: |
| *High School Name & Location: |
| Major Interests & Activities: |
| Vocational/Technical School & Location: |
| Hours Completed: |
Year Graduated: |
| Areas of Study: |
| College or University: |
| Semester Hours Completed: |
Year Graduated: |
| Areas of Study: |
| List Mapping, Appraisal, or GIS related courses successfully completed and dates of completion. You will be asked to send certificates or other documents as evidence.
|
| Affiliations |
| List national & international, professional mapping, appraisal, or GIS related organizations of which you are a member. You will be asked to send copies of membership certificates.
|
| Signatures |
I, hereby apply for admission to candidacy for the professional designation: Kansas Mapper (KM) Professional Kansas Mapper (PKM) Kansas GIS Professional (KGISP) . I certify that the information is true and correct. I agree that any further information requested of me by the Certification Committee shall be submitted in a timely manner, and will be true and correct.
It is agreed that the designation, if conferred upon me, and any certificate or emblem of designation, shall at all times remain the property of the Kansas Association of Mappers held by me in trust, and will be returned to KAM upon request of the Executive Board.
I enclose the required application fee. It is understood that the application fee will be refunded to me in full in the event that I am not admitted to candidacy. I further understand that if I am unable to fulfill the candidacy requirements during the first or second year, I will be charged an annual candidacy maintenance fee.
It is agreed that if I am certified as a KM, PKM, or KGISP, I will pay the annual dues as fixed by the Certification Committee and approved by the Executive Board.
It is further agreed that I will abide by the Code of Ethics and Standards of Conduct as well as the rules of the Certification Committee concerning the use and evidence of the Professional Designation that I may be awarded.
In submitting this application, I state to KAM that there are not now any outstanding material challenges to my professional responsibility, character, or integrity pending against me, except as explained in the attached statement dated (If none, leave black).
Signed Date |
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