euRoboticsaisbl

Secretary General Dr.Reinhard LafrenzDiamant Building,Bd.A.Reyers80B -1030Brussels, Belgium

E-mail: Web:

euRoboticsaisbl -MembershipApplicationForm

Dear prospectivemember

Thankyou foryourinterestinbecomingamemberofeuRoboticsaisbl!We wouldcertainlyliketowelcomeyouasnewmember,but firstyouneedtofill inthis MembershipApplicationForm.

A prerequisiteto answer someofthequestionsbelowand to become amember istoreadandaccept theStatutesofourorganisation. Operationaldetailsaredescribedinour organisation’sBylaws.Bothdocumentsareavailableonline at

PleasesendthefilledinanddulysignedMembershipApplicationFormtothe addressindicatedabove.

TheeuRoboticsSecretary-Generalmayrequestadditionalinformation fromyou toallowtheeuRoboticsBoard ofDirectorstobetterconsideryourapplication.Ultimately,theGeneralAssembly ofeuRoboticsaisblwilldecideaboutyourmembershipfollowingthesuggestionsof theBoardofDirectors.

Membershipcomeswith a membership fee. Thecalculationofthisfeeisbasedonyourorganisation’sturnoverorbudget. Detailscanbefoundin theeuRoboticsaisblBylaws and on the above mentioned webpage

For moreinformationvisitourwebsite:

Sincerely,

BerndLiepert,

PresidentofeuRoboticsaisbl

euRoboticsaisbl- Membership ApplicationForm

(Allfieldsmarkedwith* aremandatory.)

Applicationas*IndustryMemberResearchMemberAssociateMember

(Pleasetickoneansweronly.ForadefinitionofmembercategoriesseemembershipsectioninStatutes.)

A)Detailsof theorganisationapplying for membership

FullNameoftheOrganisation*:ShortNameoftheOrganisation:

PostalAddress:StreetNameorP.O.Box*:PostalAddress:Number*:

PostalAddress:Town*:PostalCode/Cedex*:Country*:

InternetHomepage:

If yourorganisation/companybelongstoalargergrouporisanaffiliatedcompany,pleasefillinthefollowingsection:

Affiliatedorganisation/company:Nameofaffiliatedorganisation/company:InternetHomepage:

AlreadymemberofeuRoboticsaisbl?YesNoIf yes,whatisthemembershipnumber?

Typeoforganisation* (foranexplanationpleaseseemembershipsectioninstatutes):

(Pleasetickoneansweronly.)

Companypursuingresearch,design,developmentand/ormanufacturingofrobotsinEurope

Companyhavingapartnershiprelationshiptotheroboticsindustry,eitherascomponentsupplier,serviceprovider,systemintegratororenduser.

ResearchTechnologyOrganisation(RTO)ordepartment/institute/facultyofanRTOHigherEducationEstablishment(HES)ordepartment/institute/facultyofaHESOther:

VATNumber*:
(In case you don’t have a VAT number, please explain)

If Billingaddressisdifferent frompostal addressabove,pleaseaddithere* :

BillingAddress:StreetNameorP.O.Box:BillingAddress:Number:

BillingAddress:Town:PostalCode/Cedex:Country:

LegalStatus* :

(Pleasetickonlyoneabbreviationfromthelistbelow,accordingtothefollowingexplanations:)

GOV:Governmental(local,regionalornationalpublicorgovernmentalorganisationse.g.libraries,hospitals,schools)

INO:InternationalOrganisation(i.e.aninternationalorganisationestablishedbynationalgovernments)

JRC:JointResearchCentre(theJointResearchCentreoftheEuropeanCommunity)

PUC:PublicCommercialOrganisation(i.e.commercialorganisationestablishedandownedbyapublicauthority)

PRC:PrivateCommercialOrganisationincludingConsultant(i.e.anycommercialorganisations/companyownedbyindividualseitherdirectlyorbyshares,physicalpersons)

EEIG:EuropeanEconomicInterestGroup

PNP:PrivateOrganisation,NonProfit(i.e.anyprivatelyownednon-profitorganisation).

LegalRegistrationNumber* :BusinessArea(NACECode)* :

(ForfurtherinformationonNACECodesvisitthefollowinglinks:)

Is yourorganisationanSME?*YesNo

(AnSMEisanindependentcompanywith:Lessthan250fulltimeequivalentemployeesANDeitheraturnoveroflessthan€50mORabalancesheetoflessthan€43m.)

Organisational level*

(Pleasespecifywhetheryouapplyasalegalentity(e.g.,acompanyoruniversity),orareaffiliatedwithalegalentity(e.g.,anaffiliatedcompanyofalargerholdingoradepartmentorresearchgroupofauniversity).Pleasealsospecifywhetheryouraffiliatedentityisalreadyamember:

Weapplyas

anindependentlegalentity.agovernmentalorganisation/universityanentitythatisasubgroupofalargerentitythatisalreadymember.

Nameofthatmember:

anentitythatisasubgroupofalargerentitythatisNOTamember.Nameofthatlargerentity:

My/ourapplicationrelatestoasubgroupofalargerentity.Thelevelofthissubgroupthatwerepresentisbestdescribedas(pleasetickonlyone):
Affiliatedcompany / Faculty / Department
Institute / Laboratory / Group
Other:

Is robotics yourorganisations’corebusinessorcoreresearch activity?*

YesNo

Ifyourorganisationiscommercial, isitproduct-orservice-based?

Product-based(includingcomponentandsubsystemsupply)Service-based(includingresearchandsystemintegrationservices)

Numberofstaffwhoseworkrelatestoroboticstechnology*

(full-timeequivalentemployees)

1-20 / 21- 50 / 51- 250
251-1000 / over1000

Company’sroboticsrelatedturnover/organisation’sroboticsrelatedbudget*

ThisresponsewilldeterminethemembershipfeeandthenumberoffreeticketsfortheannualEuropeanRoboticsForumERF,Europe’smostimportantnetworkingevent.Fordetails,see

€0-€200k / €200k-€2m / €2m -€10m
€10M-€50m / €50M-€100m / Over€100m

Percentageofroboticsturnoverthat is generated in Europe:

Organisationprofile* :

(Shortgeneraldescriptionof yourorganisation,ca.5linesoftext)

Roboticsrelatedactivities* :

(Morespecificsonroboticsrelatedactivitiesof yourorganisation, especially the ones in Europe,
ca.5linesoftext)

Iam interestedinactivelycontributingtothefollowingeuRoboticsaisblTopicGroup(s)

(pleasetickallthatapply)

Sectorgroups:

IndustrialRoboticsProfessionalServiceRoboticsDomesticServiceRobotics Surveillance/SecurityRoboticsSpaceRobotics Agricultural/FarmingRoboticsMedical/HealthCareRobotics EducationalRoboticsEntertainmentRobotics

Supplychaingroups:

ComponentsuppliersSystemintegratorsServiceproviders

Endusergroups(coveringexistingandnewmarketsforroboticsystems):Areaof:

Technologyrelatedgroups(asidentifiedinstrategicdocumentsandroadmaps):Areaof:

Areaof:Areaof:Areaof:Areaof:

Other:

Iam interestinfoundinganewTopicorInterestGroupinthearea(s)of:

B)MainContact Point andRepresentativeof theMemberOrganization

Familyname*
Firstname(s)*
Title
Gender* / Male / Female
Positioninorganisation*
Department/Faculty/Institute/Laboratory/GroupnameProfessionalbackground*

Phone*Email*

Internethomepage

ADDRESS OF THEMAINCONTACTPOINT(IFOTHERTHANA)

StreetnameNumber

Town

Postalcode/cedexCountry

IconfirmthatIamauthorisedtoformallyrepresentmycompany/organisationorsubgroupthereof,andhavereadtheeuRoboticsaisblstatutes.*

Date:

Signatureofrepresentative*:__

C)Legally AuthorizedContact Point

Familyname(s)*Firstname(s)*Title(s)

Nameoforganisation*Position(s)inorganisation*

I/Weherebyconfirmthecorrectnessofthismembershipapplicationformandtheinformationprovidedinthisdocument.

I/WeaccepttheeuRoboticsaisblstatutes.

I/WeherebyauthorisetherepresentativespecifiedinB)torepresentourorganisationinallmeetingsandmattersrelatedtoourmembershipineuRoboticsaisbl.

I/WeconfirmthatI/wehavethepowertoformallyrepresentmy/ourcompany/organisationorsubgroupthereofandtoauthorizetheaforementionedpersonasarepresentative.*

Date:Signature(s)*:

__