Membership Application - mainebioscience

*Company name:

*name:

*Company address (St, suite)

*City

*Zip

*Company State

*Company Country

*Company phone number

Company URL

*Company employee count - If you are note sure of the exact count, please provide estimated number.

*Company description (up to 100 words) - Briefly describe what your company does in a few sentences. This description will be used in our online members’ directory together with basic contact information.

Industry segment

Other

COMPANY CONTACTS
Primary contact information:

*Name:

*Title:

Phone number:

*e-mail address:

Billing contact
This is who we will send invoices and any questions regarding billing.

Name:

Title:

Phone number:

E-mail address:

Purchasing contact
This is who we will contact regarding cost savings programs and discounts that come with your membership.

Name:

Title:

*E-mail address:

MEMBERSHIP CATEGORY
Please select most applicable category

Membership Category