International Telework Association & Council

ONLINE MEMBERSHIP APPLICATION FORM

* = Indicates that the information is required.

Type of ITAC membership for which you are applying:*

USER: (annual dues $500)
Implements telework within their organization.

AGENCY: (annual dues $500)
Government office that promotes telework to the public or manages employee telework programs for the Agency.

VENDOR: (Dues based on annual revenue - see below)
Company that offers telework solutions including consultants, technology companies, telecommunication companies, and telework centers.
Dues based on annual revenue:

$1,000 - $1-$10 M in revenue

$3,000 - Over $10 M in revenue

SOLE PROPRIETOR/EDUCATION/NON-PROFIT: (annual dues $250)
Self-employed.

Please provide information on the Company applying for membership:

Company Name:*
Company Address 1:*
Company Address 2:
Company City:*
Company State/Province:*
Company Postal Code:
Company Country:*
Company Telephone:*

*URL with information about Company's telework programs, products or services (for inclusion in member listings on ITAC public Web site):

*50-word description of Company's business focus and/or telework products or services (for inclusion in member listings on ITAC public Web site):

Please provide information on the Primary Contact for this membership: (Provide address information if it is different than Company address)

Primary Contact Name:*
Primary Contact Title:
Primary Contact Street Address 1:
Primary Contact Street Address 2:
Primary Contact City:
Primary Contact State/Province:
Primary Contact Postal Code:
Primary Contact Country:
Primary Contact Email:*
Primary Contact Telephone:*
Primary Contact Fax:

If you are applying for membership as a: User, Agency, or Vendor, you may designate another individual from your company for membership. ITAC encourages participation from HR, facilities management and IT. (Provide address information if it is different than company address.) Send email to [email protected] to add additional individuals.

Sole Proprietors skip this section.

Additional Contact Name:
Additional Contact Title:
Additional Contact Street Address 1:
Additional Contact Street Address 2:
Additional Contact City:
Additional Contact State/Province:
Additional Contact Postal Code:
Additional Contact Country:
Additional Contact Email:
Additional Contact Telephone:
Additional Contact Fax:

PAYMENT OPTIONS:
Payment may be made via check (payable to ITAC), credit card (MasterCard, VISA or American Express) or bank transfer. Membership is not activated until payment is received

	I wish to pay by credit card. Please call me to collect my credit card information.
	I wish to pay by credit card. Please e-mail me to collect my credit card information.
	I will pay by credit card. I will fill out the form above, print before submitting, and then send via fax (480-483-8352) the following credit card information on my fax cover page: Type of credit card Name of credit card holder Credit card number Credit card expiration date
	Please contact me to arrange a wire transfer
	Please invoice me (Billing information below)

If you have chosen to be invoiced, please provide:
Billing Contact Name:
Billing Street Address 1:
Billing Street Address 2:
Billing City:
Billing State/Province:
Billing Postal Code:
Billing Country: