User Membership - Gold

Please fill out the information below and click on the 'submit' button. Click here to go back to benefits.

Fields marked with * are required. Your form submission WILL be encrypted using SSL to ensure your privacy.

BUSINESS INFORMATION
Company Information
Company Name: *
Country: *
Address: *

City: *
State: *
Zip Code: *
Province: *
Postal Code: *
Phone: *
Fax: *
Website Address:
Master Contact Information
The Master Contact will receive membership renewal notices, important updates and will serve as your company's main liaison with RIA. You must have a master contact, please be sure to notify us if there is a change in personnel.

First Name (given name): *
Last Name (family or surname): *
Job Title: *
Email: *
Telephone: *
Billing Contact Information
If no billing contact designated, membership renewal invoices will be sent to master contact.

First Name (given name):
Last Name (family or surname):
Job Title:
Email:
Telephone:
Other
Sponsoring Member:
How many employees work for your organization? *

End product(s): *	characters left

PAYMENT INFORMATION
Reference:
Payment Option
Payment Option:	Invoice Me Pay By Credit Card
To pay by check or money order print this form and send with payment to Automation Technologies Council, 900 Victors Way, Suite 140, Ann Arbor, MI 48108, USA. Checks must be in U.S. dollars drawn from a U.S. bank.
Amount:
Credit Card Type:
Credit Card Number:	(do not enter dashes or spaces)
Credit Card CSC:	(3 or 4 digit number on the back of your card)
Expires:	/ (mm/yy)
Name: (as it appears on card)