Membership Registration Form

"*" indicates required fields

Representative/Contact Name*

First Last

Title*

Organization Name*

Additional Company Members

First name

Last name

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Enter Email Confirm Email

Office Phone*

Cell Phone

Global Employee Headcount*

Industry Subsector*

Membership Level*

1-person consulting - $200.00

2 – 10 employees - $500.00

11 – 50 employees - $1,500.00

51-100 employees = $2,500.00

101 - 500 employees - $3,500.00

500+ employees - $5,000.00

NOTE: To keep membership costs low, if you choose to pay via credit card online, a 3% processing fee will be added to the cost. ($6 for $200 member; $15 for $500 member, $45 for $1500 member; $75 for $2500 member, $105 for $3,500 and $150 for $5000 member)

We also accept checks mailed to Life Science TN (618 Church Street, Suite 210, Nashville, TN, 37219), or ACH payments. Please reach out to Hannah Taylor ([email protected]) for more information.

Total

Credit Card

Card Details

Cardholder Name

Comments

This field is for validation purposes and should be left unchanged.