Membership Interest Form - Next G Alliance

Organization *

Areas of Interest

Membership Type *

Full Member
Contributing Member
Government Member

Annual Revenue *

$50 million or more
$10-50 million
Up to $10 million
Academic Institution

Annual Membership Fee: Full Membership *

$25,000.00

Annual Membership Fee: Contributing Membership ($50 million or more annual revenue) *

$10,000.00

Annual Membership Fee: Contributing Membership ($10-50 million annual revenue) *

$7,500.00

Annual Membership Fee: Contributing Membership (Up to $10 million annual revenue) *

$5,000.00

Annual Membership Fee: Contributing Membership (Academic Institution) *

$2,500.00

Annual Membership Fee: Government Membership *

$7,500.00

Primary Representative

Name *

First

Last

Title

Phone *

Email *

Additional Contact Information

Is the Primary Member Representative also the Steering Group Member? *

Yes
No
Steering Group Member has not yet been identified

Name – Steering Group Member *

First

Last

Title – Steering Group Member

Phone – Steering Group Member *

Email – Steering Group Member *

Is the Primary Member Representative also the Marketing Contact? *

Yes
No

Name – Marketing Contact *

First

Last

Title – Marketing Contact

Phone – Marketing Contact *

Email – Marketing Contact *

Is the Primary Member Representative also the Billing Contact? *

Yes
No

Name – Billing Contact *

First

Last

Title – Billing Contact

Phone – Billing Contact *

Email – Billing Contact *

Comments

Next G Alliance Operating Procedures *

Yes

Applicant agrees that, upon approval of participation in the Next G Alliance, it will abide by the Next G Alliance Operating Procedures.

Export Administration Regulations (EAR) Entity List Confirmation *

Yes

Applicant confirms it: (a) is not included on the U.S. Department of Commerce’s Export Administration Regulations (EAR) Entity List, subject to other U.S. export control laws, Executive Orders, rules or regulations (collectively “U.S. Export Regulations”) that restrict its receipt of or access to information, data, or technology (collectively “Information”) that is of the sort that is disclosed, exchanged, or transferred in the ordinary course of ATIS activities, and at the time of this application is not in violation of any U.S. Export Regulations that restrict its receipt or transfer of Information; and (b) will immediately notify ATIS if the foregoing confirmation becomes in any way inaccurate once it becomes an ATIS member. It is understood that a failure to provide the foregoing confirmation will cause rejection of Applicant’s request for membership in ATIS, and a failure to provide the required notification once a member will result in suspension of Applicant’s membership.

Date