Internet2 Industry Membership Application

Date

Organization Name*

Primary Address*

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

Email*

Number of Locations*

Chief Executive Officer*

Chief Information Officer*

Website URL*

A. Describe your core business*

B. Describe your interest in Internet2*

C. Membership Level

Internet2 Industry membership is divided into four levels, based on each organization’s annual revenues. Beneﬁts and requirements vary by level.

See internet2.edu/membership for more details.

The Internet2 membership billing period is from January 1—December 31 of the current year. If a pre-invoice quote or PO number is required, please contact accounting@internet2.edu. Network Participation fees will be billed separately, as applicable. Please note: Membership and Network Participation are covered under separate agreements, as not all Industry members require an Internet2 connection.

UCAID (Internet2) Federal ID #: 52-206-0187

Annual Revenue*

Membership Dues	Fees	Total
Level 1 Connected: $39,079 Level 1 Non-connected: $39,079 Revenues>$1 billion	$30,235 n/a	$69,314 $39,079
Level 2 Connected: $37,127 Level 2 Non-connected: $27,173 Revenues $500 million <$1 billion	$30,235 n/a	$67,632 $27,173
Level 3 Connected: $35,170 Level 3 Non-Connected: $15,268 Revenues $10 million <$500 million	$27,218 n/a	$62,388 $15,268
Level 4 Connected: $11,630 Level 4 Non-Connected: $2,912 Revenues <$10 million	$27,218 n/a	$38,848 $2,912

D. Proposed Internet2 Contacts

Executive Liaison Contact The Executive Liaison serves as the main contact for your organization and is responsible for gathering and disseminating general information about Internet2 activities to your community and assigning the other Internet2 representative roles. The Executive Liaison is ultimately responsible for payment of dues and assessments and serves as the oﬃcial voting representative for your organization.

Name

First Last

Title

Address (if different from above)

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

Phone

Scheduling Assistant (if applicable)

Assistant Email (if applicable)

Membership Billing Contact

The Membership Billing Contact receives the invoices for Internet2 membership dues and Internet2 Network fees (as applicable). For more information, please contact membership@internet2.edu

Name*

First Last

Title

Address (if different from above)

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

Phone

Email*

Government Relations Contact

The Government Relations Contact is responsible for tracking government-related Internet initiatives and evaluating their relevance to activities within your organization. Other responsibilities include disseminating messages from the member update mailing lists. For more information, please contact membership@internet2.edu

Name*

First Last

Title

Address*

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

Phone

Email

Public Affairs Contact

The Public Aﬀairs Contact is responsible for promoting Internet2 activities within your organization. This may include press releases, electronic and print publications and using the Internet2 logo on internal printed material. The representative may post messages to the Internet2 news mailing list and may disseminate messages.

Name*

First Last

Title

Address*

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

Phone

Email*

E. Corporate Logo

If you are joining Internet2 as a Corporate Partner or Sponsor, please send the logo you would like displayed on our website to: membership@internet2.edu. We accept .gif, .jpg or .tif formats.

Upload file

Max. file size: 10 MB.

F. Submit Application

Application submitted by (title):*

Phone

Submitter Email*

Internet2 Industry Membership Application

Fill out this form to apply for Industry membership

Please contribute as much detail as possible