MEMBERSHIP APPLICATION

If you would like to become a member of this exciting and growing group, please fill out the form. Make sure that you fill out every area that has an asterisk. Once the form is filled out and we receive it, we will contact you immediately and send you all the information that you need to become an interactive member of the PC/104 Consortium.

Items marked with an asterisk (*) must be filled in!

Contact Details
	Company:	*
	Address, Line 1:	*
	Address, Line 2:
	City:	*
	State/Province:	*
	Zip/Postal Code:	*
	Country:	*

	Telephone:	*
	Fax:
	Company E-Mail:	*
	Company URL (with http://) :

Primary Contact
	Name:	*
	Title:	*
	Email:	*

Secondary Contact
	Name:
	Title:
	Email:


Membership Category
	Executive ($5000 US per year)
	Associate ($1750 US per year)
	Affiliate ($750 US per year)
Payment Type:
	Credit Card
	Check or Wire Transfer
	Please Invoice Me
Membership payments are non-refundable. *Please check this box to indicate that you have read, and agree to be bound by, the Bylaws of the PC/104 Consortium, then click the 'Join' button below to send your application.

Thank you for joining the PC/104 Consortium.