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2012 Membership Application

Complete and submit the application form below. If your WWW client does not support forms,
fax this application to +1.510.492.4001 or e-mail it to info@broadband-forum.org.

* Required field.

Membership Contact Information

Primary Representative:

First Name*
Last Name*
Company*
Job Title
Address*
Mail Stop
City*
State
Zip*
Country*
Telephone*
Fax
Email*

Secondary Representative:

First Name*
Last Name*
Job Title
Address*
Mail Stop
City*
State
Zip*
Country*
Telephone*
Fax
Email*

Marketing/PR Representative:

First Name*
Last Name*
Company
Job Title
Address*
Mail Stop
City*
State
Zip*
Country*
Telephone*
Fax
Email*

Invoice Representative:

First Name*
Last Name*
Job Title
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Company URL
Membership Affiliation
*Per the Broadband Forum Bylaws, Article 3.2.1, please state whether your company has any affiliations or sister entity companies that are already members of the Broadband Forum.

Affiliate means, with respect to any designated Person, any other Person who, directly or indirectly, is controlled by, or is under common control with, including without limitation any general partner, managing member, officer or director of such Person. Sister Entity means, with respect to any designated Person, any other Person who directly, or indirectly through one or more intermediaries, is under common control with such designated Person.
Yes
No
If yes please state member company - name and type of affiliation:
Industry Resource Guide Company Listing
If you would like to be placed in our Industry Resource Guide, please check all that apply:
Semiconductor Company
Modem Supplier
Network Access Equipment Supplier
Subscriber Management Systems
Broadband Remote Aggregation Servers
Network/Service Provider
Testing/Management Supplier
Independent Test Lab
Software Manufacturer
Consultant
Non-Profit or Educational Body
Other - please explain:

How did you hear about us? (Please check all that apply)
Industry Conference
Tradeshow
Publication
Colleague/ Industry Contact
Website
Other - please explain:
What is your reason for joining The Broadband Forum? (Please check all that apply)
Technical Work/ Specifications
Broadband Marketing Initiatives
Industry Networking
Corporate Positioning
Interop Events Participation
Other - please explain:
-- Membership Options --
Please choose one payment option
and fax a signed copy of the Bylaws to the Forum at +1.510.492.4001
Principal Membership
4 quarters
January 1, 2012 - December 31, 2012		 $10,950.00 USD
Small Company Principal Membership
(revenue less than $20 million USD)
4 quarters
January 1, 2012 - December 31, 2012		 $5,250.00 USD
Auditing Membership
4 quarters
January 1, 2012 - December 31, 2012		 $4,250.00 USD
Associate Membership
(not for profit, educational institutions only)
4 quarters
January 1, 2012 - December 31, 2012		 $1,100.00 USD
Method of Payment
PLEASE NOTE: Once your application is received and payment processed, there will be no refunds issued.
Checks made payable to: The Broadband Forum
I will pay by:
Account Number
4 digit security code
Expiration Date
Name of Cardholder
Cardholder Billing Address 



Wire Transfer Information:


**Broadband Forum applicants are responsible for all wire transfer fees or any other banking fees. Please calculate fees and dues when sending payments. Fees may not be deducted from annual membership dues.**

Wells Fargo




Fremont, CA 


Wire Transit Number: 121000248


Swift Code: WFBIUS6S


Account Name:  The Broadband Forum


Money Market Account #: Please contact the Forum













Forum Contact Information:


The Broadband Forum


48377 Fremont Blvd., Ste 117


Fremont, CA 94538


Ph: +1.510.492.4020


Fx: +1.510.492.4001


info@broadband-forum.org