ITIA Membership Signup - Company Info, logo and release

Indiana Technology & Innovation Association Application

Membership Type*

Member Associate Member

Company Name (or Individual, if joining as an individual) *

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Contact Name*

First Name

Last Name

Title

Email*

Phone Number*

Assistant's Name

First Name

Last Name

Assistant's Email

Assistant's Phone Number

Logo

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Membership / Associate Membership Level*

$500 / year: Startup Member (annual revenue less than $1M) $1,000 / year: Scaleup Member (annual revenue between $1M-$10M) $5,000 / year: Growth Member (annual revenue between $10M-$25M) $10,000 / year: Premier Member (annual revenue greater than $25M)

Authorization and Release*

I hereby grant permission for our company name and logo (or individual name if joining as an individual) to be listed publicly as a member of the Indiana Technology & Innovation Association for any general association membership announcements and promotional materials.