Organization Name: First Name: Last Name: Job Title: Email: Home Phone: Home Address: City: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming American Samoa Federated States of Micronesia Guam Marshall Islands Northern Mariana Islands Palau Puerto Rico U.S. Minor Outlying Islands Virgin Islands Armed Forces Americas Armed Forces Europe, the Middle East, an Armed Forces Pacific Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Territory Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory Zip: - Zip Suffix Current Membership Level: Primary Contact Name Invoice Contact Name Invoice Contact Email Communications/Media Contact Name Communications/Media Contact Email Desired Membership Level (if different from above. We offer a 10% discount for upgrading your membership!) Business Platinum Membership - $2,300 Business Gold Membership - $1,175 Business Silver Membership - $600 Government Membership - $300 Academic Membership - $300 Associate Membership - $300 Individual Membership - $120 Partner (Swap) Membership - $0 Would you like to join one of our three, year round advisory committees? Membership Education and Events Policy and Programs Not at this time I already participate in a committee