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1. Company Information

Company Name*             


Address*
Street Address                                                                        Suite Number

City                                             State/Province                                      ZIP or Postal Code
Select State or Province ------------------------ Alabama Alaska Alberta American Samoa Arizona Arkansas Australian Capital Territory British Columbia California Colorado Connecticut Delaware District of Columbia Eastern Florida Free State Gauteng Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky KwaZulu-Natal Limpopo Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Mpumalanga Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New South Wales New York Newfoundland North Carolina North Dakota North West North West Territories Northern Cape Northern Mariana Islands Northern Territory Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Queensland Rhode Island Saskatchewan South Australia South Carolina South Dakota Tasmania Tennessee Texas Utah Vermont Victoria Virgin Islands Virginia Washington West Virginia Western Australia Western Cape Wisconsin Wyoming Yukon Territory
Country or Territory                                                        
Select Country or Territory ------------------------ Afghanistan Albania Algeria Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas, The Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil British Virgin Islands Brunei Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China, People’s Republic of China, Republic of Colombia Comoros Congo, Democratic Republic of the Congo, Republic of the Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Islas Malvinas) Faroe Islands Fiji Finland France French Guiana Gabon Gambia, The Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guatemala Guinea Guinea-Bissau Guyana Haiti Holy See (Vatican City) Honduras Hong Kong S.A.R. Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea, North Korea, South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau S.A.R. Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Mauritania Mauritius Mexico Moldova Monaco Mongolia Montenegro Morocco Mozambique Namibia Nauru Nepal Netherlands New Zealand Nicaragua Niger Nigeria Niue Norway Oman Pakistan Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Qatar Romania Russia Rwanda Saint Kitts and Nevis Saint Lucia Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Tajikistan Tanzania Thailand Timor-Leste Togo Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Venezuela Vietnam Virgin Islands Wake Island Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe  

Company Description*
Please describe briefly the type of company, including size, principal client type, principal areas of operation and overview of key services/products:



2. Key Personnel Information

Primary Contact Person for this Application*
Title               First Name                                Last Name             
Mr. Ms. Mrs. Dr. Other
Telephone                                  Facsimile                                   E-mail Address


Secondary Contact Person for this Application
Title            First Name                            Last Name            
Mr. Ms. Mrs. Dr. Other
Telephone                              Facsimile                               E-mail Address


The following contact details are not mandatory. However, the following contact details are necessary to enable IPOA to more efficiently provide better member services to your company if this application is approved.

Accounting/Finances
The officer within your company with whom IPOA should correspond on matters of invoicing and finances:
Title              First Name                                Last Name            
Mr. Ms. Mrs. Dr. Other
Telephone                                 E-mail Address


Business Development
The officer within your company with whom IPOA should correspond on matters of business development:
Title              First Name                                 Last Name            
Mr. Ms. Mrs. Dr. Other
Telephone                                 E-mail Address


Communications, Marketing and Public Relations
The officer within your company with whom IPOA should correspond on matters of communications, marketing and public relations:
Title              First Name                                 Last Name            
Mr. Ms. Mrs. Dr. Other
Telephone                                 E-mail Address


Ethics or Compliance
The officer within your company with whom IPOA should correspond on matters of internal standards, ethics and compliance:
Title              First Name                                Last Name            
Mr. Ms. Mrs. Dr. Other
Telephone                                 E-mail Address


Government Affairs
The officer within your company with whom IPOA should correspond on matters of government affairs:
Title              First Name                                Last Name            
Mr. Ms. Mrs. Dr. Other
Telephone                                 E-mail Address


Legal Affairs
The officer within your company with whom IPOA should correspond on matters of law (i.e., general counsel):
Title              First Name                                Last Name            
Mr. Ms. Mrs. Dr. Other
Telephone                                 E-mail Address


Human Resources or Recruiting
The officer within your company with whom IPOA should correspond on matters of recruitment:
Title              First Name                                Last Name            
Mr. Ms. Mrs. Dr. Other
Telephone                                  E-mail Address



3. Membership Application Information

Type of Membership* (Select One)
          General Membership ($8,000 per year)
          Small Company General Membership ($5,000 per year)
                   Available only to companies with $3 million annual revenue or less
          Associate Membership ($2,000)
                   Available only to product companies and includes only partial privileges

Additional Information
E-mail these required documents to development@ipoaonline.org.

• Please send us a Past Performance Package for review
• Please provide IPOA a list of your firm's Principals (Board of Directors, VP and Director-level executives, etc.)