Main Representative
Name			Title
Phone or Ext		Fax	Email
Is the Main Representative also the Billing Contact for future Invoices ? Yes No (If No, please fill out billing contact below.)

Billing Contact
Name			Title
Phone or Ext		Fax	Email

Please Provide company representatives requested below (You do not need to repeat email addresses if already listed above)
Chief Executive Officer		Email
Chief Information Officer		Email
Chief Financial Officer		Email
HR / Personnel Director		Email
PR / Marketing Director		Email

Others to Receive TCCP Newsletter and Calendar of Events
Name			Title
Phone or Ext		Fax	Email

Name			Title
Phone or Ext		Fax	Email
Use the space below if there are additional names. Sign-up as many as you want - no limit

Please indicate your top 3 reasons for joining (in numeric order of priority)
	Networking Opportunities		Venture Investment Opportunities		Internet Services/Links
	Economic Development		Member Referrals		Entrepreneurial Assistance
	Marketing/Advertising Opportunities		Events / Functions		Technology Enhancement
	Seminars/Training/Programs		Governmental Representation		Committee Involvement
	Workforce/Staffing Issues		Other

Please Provide the Following Information
Total Gross Revenue	$	Total Number of Employees	#

Membership Dues Rate Card

Please use the chart below to determine your annual membership dues for the Technology Council.

Select Your Dues Amount

Dues Amount 1-9 Employees $500 10 to 99 Employees $1,000 100 to 499 Employees $2,500 500 or More Employees $5,000 Student Chapter of Tech Council $250 Non-Profit Organization $350 School District $350 Government Agency/Dept $500 Economic Development Corporation $500 College/University/Higher Educ $500 Student: If you're a student (high school, or college) you're eligible to become a student member of TCCP Student Membership $30

Method of Payment
	Membership Dues based on above chart		$
	Pay online via PayPal ---- !!!!!Choosing this option will redirect you to the PayPal site. You MUST send the application to us by clicking on the Send Application at the bottom of this page to forward your completed application to us.
	Check --- should be mailed and be made payable to:
		Technology Council of Central Pennsylvania 415 Market Street, Suite 201 Harrisburg, PA 17101

Investors have a special relationship with the Technology Council. An investor supports the Council's mission of strengthening the region's technology community. Investors receive special recognition throughout the year. Call (717) 635-2113 to learn more about this special-member category.

Chairman's Circle $100,000 President's Circle $50,000 Platinum $20,000 Gold $10,000 Silver $7,500 Bronze $5,000

Referral Source -- Important: Please tell us how you found out about the Tech Council of Central PA. Did someone refer you to us? Did you attend one of our events or programs? Do you receive our newsletter? Did you read about us in an article?