PoE Consortium Membership Application

Company name*

Company seeking membership

Description*

Description of the company or organization applying for membership (25-75 words)

Website URL*

Date of Company Founding (Year)*

Membership Level*

Patron Member ($5,000)

Member ($1,000)

Observer ($250)

URL to Company Logo

Please include a link to your official company logo for marketing use

Contact Information: Who is the main contact and representative for the company?

First name*

Last name*

Job title*

Phone number*

Email*

Street address*

This is your physical mailing address, as the primary contact for the company.

City*

State/Region*

Postal code*

Billing Information

Please fill out this information if the billing contact and information is different from the contact person above.

Participant Name

Please include the first and last name of the billing contact at your company, if different from above.

Billing Email

Please include the email of the billing contact at your company, if different from above.

Phone number

Street address

Street address 2

City

State/Region

Postal code

Country/Region

Message

Additional comments?

By submitting this application, the company applying for membership in the PoE Consortium agrees to pay the relevant annual dues associated with the level of membership selected above. All members who apply in 2022 will be billed for 2023 membership the first week of January, 2023. There will be several options for payment. All payments must be made within 30 days of invoicing or membership will be revoked. By checking this box, you are agreeing to these terms:

Consent to Billing*