IPG, Inc.

Certification Application

Please open up your browser window all the way, and, using the PRINT function on your browser, you may print this page, fill it out completely, and mail with your check to: IPG, Inc., Linda Easton / Treasurer, 6475 Wallace Rd NW, Salem, OR 97304 or call: 503-551-2397

if you have questions. Thank you!

Certification Date:__________________________

Location:_________________________________

Name:___________________________________

Salon Name:______________________________

Address:_________________________________

City/State/Zip:_____________________________

Home Address:____________________________

City/State/Zip:_____________________________

Bus. Phone:_______________________________

Home Phone:_____________________________

Are you currently certified with any other grooming organization? ______Yes ______No

If "Yes", tell us which organization you are certified with and in what categories (if applicable) you hold certification.

Organization:_______________________________________

Categories:___________________________________________________________

____________________________________________________________________

______I am a current member of IPG.

______Please enroll me as a Member. I have enclosed my $75 membership fee. (You must be a member to participate in certification testing.)

______Consecutive Year Renewal $50 (To be paid by March 31 of current year.)

Certification Fees:
$20 Guidelines
$65 Practical Only
$35 Written Only
$100 Master Exam
$5 Window Decal
(All Amounts are in US Funds Only)

Please mark the categories you will be testing in:

____Non-Sporting Practical	____Non-Sporting Written
____Sporting Practical	____Sporting Written
____Terrier Practical	____Terrier Written
____Master Exam

I will be paying my annual dues using: check # ___________ (please don't send cash in the mail)

______Money Order

I agree to absolve the officers and directors of IPG, Inc. and the officers and members of hosting organizations, of any legal claim for loss or injury to myself or my dog while attending and participating in IPG, Inc. Certification Testing. I further agree to abide by all rules, regulations and Code of Ethics of IPG, Inc. and to accept the Certifier's decision as final and binding.

Applicant's Signature:______________________________ Date:______________________