(Please Print)

Name:                                     ___________________________________________


Address:                                ___________________________________________


City, State & ZIP+4              ___________________________-_______________


Phone:            _____-_____-__________              FAX:            _____-_____-__________


E-mail Address:                    ___________________________________________


I currently rose bushes of the following types (show quantity of each):


HT ____  GR ____  FL ____  Mini ____  CL ____  Shrub ____  OGR ____  Total ____              

I have been an American Rose Society Member since ______________. I have served on the following District Committees (indicate if served as Chair): ____________________________________________________________________________________________________________________________________________________


I am an active member of the _______________________ RS in _____________________,

                                                     Name                                                City, State

having been a member since: __________. I have held office in the following local rose society capacity(s): ____________________________________________________________________________________________________________________________________________________


I have given the following programs: ____________________________________________________________________________________________________________________________________________________


I have written the following articles (give publications): ____________________________________________________________________________________________________________________________________________________


I have attended ____ District Conventions and ____ ARS National Conventions.


I hereby affirm that the above information is correct, and that I have read and understand the responsibilities of a Consulting Rosarian as printed in the ARS Consulting Rosarian Manual.


Signed: _____________________________________________   Date ________________


Send this form to your District Consulting Rosarian Chair; and send a copy of this Form plus a copy of Form NCRLR to at least 3 active CRs for their recommendation, all at least 45 days prior to a CR School.


Form NCRA, Rev. 0, 27AUG01