Eastern Technology Council

Membership Form

Please fill out the form below to submit your application to join the Eastern Technology Council. Note that fields with a red asterisk (*) next to them are required.

General Information

Company Name:
*

Membership Type

Select your type of membership:
*

Regional Contact Information

Address of regional office:
*

*

Business Phone Number:
* Example: (xxx) xxx-xxxx ext. xxxx

Business Fax Number:
Example: (xxx) xxx-xxxx ext. xxxx

Contact Email:
*

Company Web Site URL:
Example: http://www.example.com

Corporate Information

Total Number of Employees:

Regional Number of Employees:

Area Served:

Gross Total Annual Sales:

Gross Regional Annual Sales:

Year Established:

Is your company publically owned?

Public Market (if applicable):

Public Market Symbol (if applicable):

Company Description:

Primary Contact Information

First Name:
*

Last Name:
*

Email:
*

Payment Information

Annual dues are based on your company's membership type. Industry membership's dues are based on annual gross revenues. Service membership's dues are based on current employment numbers.

Industry Membership Dues

Annual Revenue	Annual Dues
Less than $1M	$550
$1M - $5M	$825
$5M - $10M	$1,210
$10M - $25M	$1,650
$25M - $50M	$2,420
$50M - $100M	$3,300
$100M - $250M	$4,400
$250M - $500M	$5,500
$500M and above	$6,000

Service Membership Dues

Current Employment	Annual Dues
1 - 9	$550
10 - 49	$825
50 - 99	$1,210
100 - 199	$1,650
200 - 299	$2,420
300 - 499	$3,300
500 - 999	$4,400
1,000 - 2,499	$5,500
2,500 and above	$6,000