New Membership Information Form


    STEP 1
    Organizational Information

    Organization Name*:

    Website:

    Billing Street*:

    Billing City*:

    Billing State/Province*:

    Billing Zip/Postal Code*:

    Billing Country*:

    Sector*:

    Annual Spend*:

    Select the appropriate Membership Tier for your sector:

    Membership Tier*:

    The Sector and Membership Tier selected above determines your dues. Based on your selection above, your estimated dues are:

    I confirm that the Sector and Membership Tier selected for my organization is correct, and can be validated with supporting documentation as described in SPLC’s Membership Policy*.

    Industry*:

    Minority-Owned Business?* YesNo

    Woman-Owned Business?* YesNo

    SPLC Member?* YesNoNot sure


    STEP 2
    Contact information

    Primary Representative

    First Name*:

    Last Name*:

    Title*:

    Email Address*:

    Department*:

    Phone*:

    Secondary Representative

    First Name*:

    Last Name*:

    Title*:

    Email Address*:

    Department*:

    Phone*:

    Billing Representative

    First Name*:

    Last Name*:

    Title*:

    Email Address*:

    Department*:

    Phone*:

    Please indicate which Representative(s) should receive your annual membership dues invoice.
    Billing RepresentativePrimary RepresentativeSecondary Representative

    How did you hear about us? (Select all that apply)*
    Attended an SPLC eventEmail from SPLCReferral from a colleagueSearch engineSocial MediaTown HallWord of mouth