ATIA 2004 Membership Application

ATIA 2016Membership Application

ATIA 2016 Membership is active fromJanuary 1, 2015 through December 31, 2016

“ATIA is exempt from Federal income tax under Section 501(a) of the Internal Revenue Code, as a Section of 501(c)(6) organization. Membership payments to ATIA are not deductible as charitable contributions, but may be deductible as ordinary and necessary business expenses. Members should consult their tax advisors for further information.”

CHECK ONE: New Member______Member Renewal______

Company:

CEO: CEO Email:

Street Address:

City: State/Province: Zip+4/Postal Code:

Main Company Number:800 Number:

Fax Number: E-mail Address: Web Site:

Primary Contact Information:

PRIME Contact Name: Title:

PRIME Contact email: Phone Number:

Member Referral: Referred by: Contact NameCompany Name

Membership Options: (Check One)

Regular Membership – Annual Revenues under $500K - $650

Regular Membership – Annual Revenues of $500K-$99M - $1,250

Regular Membership – Annual Revenues over $99M - $4,600

Associate Publisher - $650*

Associate Distributor - $200*

* Members at the Associate level do not carry association voting privileges and are ineligible to serve as Board Directors.

REMINDER: Membershipshould be renewed by 2/29/16to be eligible to receive the $1,800 Member Booth rateat the ATIA 2017 Orlando Conference. Member Booths fees are $2,000 from 3/1/16. Booths may be purchased later, but membership must be renewed by 3/31/15 to be eligible for Member Booth fees. Non-Member Booth fees are $3,550, almost twice as much as Member Booth rates.

Payment Options:

Check - For direct payment all applications should be mailed with the appropriate Membership Fee to:

ATIA - Membership, 8332 Solutions Center, Chicago, IL 60677-8003

Purchase Order/PO – Federal ID #77-0482095. The Purchase Order must be made payable to:

ATIA - Membership, 8332 Solutions Center, Chicago, IL 60677-8003

Credit Card – American Express, MasterCard and Visa only. Membership applications paid by credit card may be paid online by contacting .

COMPANY PROFILE

Company Name: ______

DEMOGRAPHIC PROFILE

1. Area of Expertise (REQUIRED INFORMATION): Please indicate your area of expertise (check all that apply):

❑AAC❑K-12 Education Technology

❑Accessibility❑Information Technology

❑Blindness❑Low Vision

❑Cognitive Disabilities❑Physical Disabilities

❑Computer Access❑Rehabilitation

❑Deafness / Hard of Hearing❑Web Accessibility

❑Workplace

❑Other (please specify :______)

2. CEO Name and Email (for use for selected CEO level communications only) (REQUIRED INFORMATION):

Name: ______Email: ______

3. What other Association or Industry Groups are you a member of: ______

4. Comments / Notes

ATIA Headquarters • 330 North Wabash Avenue, 20th Floor • Chicago, IL 60611 USA |Page1|

Toll-Free: 877-687-2842 • Phone: 312-321-5172 • Fax: 312-673-6659 •E-mail: •