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AIA Affiliate Member Application:

Please fill out the information below and click on the 'submit' button. Click here to go back to benefits.
Fields marked with * are required. Your form submission WILL be encrypted using SSL to ensure your privacy.

Company Type:
Please select one: *
Research Organization
Government Agency
Independent Consultant

Business Information:
Company Information
Company Name: *
Address: *
City: *
Zip/Postal Code: *
Country: *
Telephone: *
Website Address: *
If the address above is not your company’s corporate/world headquarters, please list the Country where your headquarters are located:
Corporate Headquarters Country:
Your Company Logo:
Upload for display on your company profile. Format: gif, jpg, or png - if possible 250 pixels wide x 125 pixels high
How did you hear about us:
Master Contact Information
The Master Contact will receive membership renewal notices, important updates and will serve as your company's main liaison with AIA. You must have a master contact, please be sure to notify us if there is a change in personnel.
First Name (given name): *
Last Name (family or surname): *
Job Title: *
Email: *
Telephone: *
Billing Contact Information
If no billing contact designated, membership renewal invoices will be sent to master contact.
First Name (given name):
Last Name (family or surname):
Job Title:
Marketing Contact Information
If no marketing contact is designated, marketing information will be sent to master contact.
First Name (given name):
Last Name (family or surname):
Job Title:

Billing Options:

Indicate how you would like to pay. We must receive your payment before your membership can be processed.

Promo Code:
Note: Promo Code is case sensitive.
Method of Payment
Payment Option: Invoice Me Pay By Credit Card
To Pay by check or Bank Transfer, please print a portion of this form, then submit your membership application. If paying by check, please make payable and send to Association for Advancing Automation, 900 Victors Way, Suite 140, Ann Arbor, MI 48108, USA. Checks must be in US dollars drawn from a US bank. For Bank Transfer information please contact Sarah LeCouffe (slecouffe@robotics.org). If you are using Bank Transfer, please note in your transfer that payment is for Membership, all companies are responsible for any and all fees incurred.
Amount: $
Credit Card Type:
Credit Card Number: (do not enter dashes or spaces)
Credit Card CSC: (3 or 4 digit number on the back of your card)
Expires: / (mm/yyyy)
Name: (as it appears on card)
Comments: 100 characters or less

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