MEMBERSHIP APPLICATION

Member Representative Name:
Employer:
Position or Title:
Business Address:
City: State: Zip:
Business Tel: Business Fax:
E-mail Address: Website:

Provide names of up to four (4) additional people (with email addresses) within your organization that may wish to
obtain information about BioNorthTX:
Name 1: E-mail 1:
Name 2: E-mail 2:
Name 3: E-mail 3:
Name 4: E-mail 4:

Please list name of person responsible for purchasing in your company:
E-mail: Phone Number:

Please check if applicable:
Yes, please list my company name and website in the BioNorthTX website membership directory

Please check off areas of interest to you and your company regarding costs savings through the THBI/BIO Business
Solutions national purchasing program. This discount program is a free member benefit. Savings will exceed the cost of
your BioNorthTX membership!

Please indicate below what membership category your company falls into for verification of annual membership
dues.

Life Science Members - All dues based on total number of full-time employees worldwide. Definition: Companies and organizations that working in fields that include: Research, Biotechnology, Medical Device & Equipment, Pharmaceuticals & Therapeutics, Nanotechnology, Diagnostics, and Product Development/Drug Discovery Firms.

Associate Members - All dues based on total number of full-time employees worldwide. Definition: Companies and institutions that are not directly involved in commercial biotechnology/life science product development or commercialization, but share an interest in the industry's future and provide service or products to Life Science companies. Examples: Professional Services (consulting, law, insurance, HR Solutions. marketing, VC & investment firms, financial services, real estate, site selection, product sales & distribution, service IT providers, etc.), Health & Life Science IT (Medical Records, R&D, Wellness, Revenue Cycle, etc.), Contract Research (Clinical & Pre-Clinical Trials, Trial Data Management), Marketing, Sales, Laboratories & Testing Services, etc.

Institutional Members - All dues based on total number of full-time employees worldwide. Definition: Institutions and organizations involved with bioscience research & development, care delivery, education, and advocacy, Clinics/Hospitals, Colleges/Universities, Research Institutions, Non-Profit Disease Related groups or industry trade associations/professional organizations.

Individual members -Definition: Individuals, job seekers and students interested in the life science industry

On behalf of my organization, by submitting this form I hereby apply for membership in BioNorthTX and agree to pay all membership dues promptly at renewal. I will also ensure that other individuals at my organization are aware of the benefits of membership. If I am to leave my organization, I will notify BioNorthTX of my replacement as Member Representative.

Please return this form with a check payable to BioNorthTX, 1400 Civic Place, Suite 221, Southlake, Texas, 76092. Or, you
may request an electronic invoice for payment by Credit Card or PayPal.
Send electronic invoice
Check enclosed in the amount of $

BioNorthTX is designated as a 501(c)(6) trade association. Membership dues may constitute a business expense but are not a
charitable deduction at this time.