Member Company Qualification Statement

Must be signed by Officer (Owner, President, CEO, CFO, or Vice President) of Member Firm

APPLICANTS
If you are an applicant, please contact the owner or officer and have them log on to the NorCal MCA site to submit this form.

NORCAL MCA OWNER OR OFFICER
Please fill in the following information, then click "Submit."
Begin by providing your name and email address.

REGISTRANT INFORMATION = Owner of Officer's name and email.


This is to certify that
is the parent of
who has applied for the Northern California MCA Kent T. Morrill Scholarship Program. This parent has been employed or associated full time with

and has been with this company since
in the capacity of
at the following location

So certified,


I certify that the above information is correct AND that the qualifying parent listed above is NOT a member of any Union affiliated with or signatory to the Member Company listed above.