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NYBA:
Application
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Application
Note: Items in marked with asterisk(
*
) are required
General Information :
Please provide the following information:
*
Title (Dr., Mr., Ms.)
*
Voting Member
(Full name)
*
Email Address
*
Name of Organization
*
Mailing Address
*
City, State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
14-4000 Liege
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territory
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Saskatchewan
Yukon Territor
Quebec
*
Zip
*
Telephone
Fax
WWW Address
*
Description of Business
*
Number of Employees
*
Business Sector
--Please Select--
Accounting
Advertising/Public Relations
Biotechnology/Pharmaceuticals
Consulting
Contract Manufacturing
Contract Research
Economic Development
Financial
Insurance
Law
Real Estate
Research Institutions
Search Firms
Suppliers
Utility
*
Business Sector Subcategory
--Please Select--
Logo
(Dimension 150 X 120 pixels, Size up to 100 KB)
Membership Categories:
Your NYBA membership is based upon your company's category and the number of employees worldwide. Please check off the appropriate category and number of employees.
Core:
Organizations that develop, manufacture and commercialize products based upon the practical applications of the biological sciences.
1-5 employees,
Dues= $400.00
6-15,
Dues= $880.00
16-50,
Dues= $1320.00
51-100,
Dues= $2310.00
101-250,
Dues= $2750.00
251-500,
Dues= $3750.00
Over 500,
Dues= $5445.00
Support:
Organizations that provide devices, equipment, supplies or services to the biotechnology, biomedical or bioengineering industries.
1-25 employees,
Dues= $935.00
26-50,
Dues= $1870.00
51-100,
Dues= $2640.00
101-300,
Dues= $4620.00
Over 300,
Dues= $6050.00
Institutional:
Non-profit research laboratories, academic medical centers, universities, or government bodies with an interest or involvement in biotechnology.
Institution employees,
Dues= $1850.00
Academic Scientist,
Dues= $100.00
Post Doc. Fellow,
Dues= $50.00
Please provide names of people in your organization:
Business Development
Name :
Email :
CFO
Name :
Email :
Human Resource
Name :
Email :
Purchasing Department
Name :
Email :
Communications Director
Name :
Email :
Payment Information:
Please note: if you would prefer to give us your credit card number over the phone, please check the below check-box and we will contact you. If you are paying by check, your membership is effective once payment has been received.
Credit Card
Check
Account Number
Expiration (mm/yyyy)
Cardholder's Name
Amount Authorized to Charge
Account Number
Routing Number
Check Number
Account holder Name
Amount Authorized to Charge
*
Enter Code: (Case Sensitive)
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