Member Application - Pennsylvania Society for Biomedical Research

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PSBR Membership Application

INFORMATION PAGE: Membership is open to institutions, organizations, health voluntaries, and professional associations who support the mission of PSBR and contribute $500 or more a year. The Society welcomes contributions from individuals in any amount.

MEMBER FEE SCHEDULE AND BENEFITS: Members at dues contribution levels of $5,000.00 or higher are eligible for representation on the Board of Directors. This provides a direct voice in the direction and activities of the organization.

BENEFACTOR: $15,000 or more - Patron benefits plus: 3 BOD members and/or votes, First option to Underwrite Special Projects, Three paid participants at PSBR sponsored functions

PATRON: $10,000 to $14,999 - Sponsor benefits plus: 2 BOD members and/or votes, Priority Option to Underwrite Special Projects, Two paid participants at PSBR sponsored functions

PARTNER: $1,500 to $4,999 - Friend Benefits plus: Annual speaker for students, IACUC, staff or leadership; Discounts for all organization members at PSBR sponsored functions

FRIEND: $500 to $1,499 - E-mail updates, Alerts on anti-research activities, Crisis support, Invitation to annual dinner

All members are provided with crisis support, free advocacy materials, and access to the member network. All members are also provided with discounts for SUBR (States United for Biomedical Research) sponsored events and services.

PSBR is a 501 (c)(3) non-profit science education organization, founded in 1990, and incorporated in 1991.

PO Box 1163, Camp Hill, PA 17001-1163

MEMBER INFORMATION AND KEY CONTACT FORM:

Person Completing this Form*

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Organization Name*

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Type of Organization: (e.g., academic center, supplier, biotechnology firm, etc.)*

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Mailing Address Street*

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City*

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State*

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Zip Code*

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Phone Number (xxx-xxx-xxxx)*

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Company Website Address*

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PRIMARY INSTITUTION CONTACT INFORMATION:

Primary Institution Contact Person*

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Title*

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Telephone Number*

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Email Address*

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MEMBERSHIP LEVEL:

Membership Level*

Benefactor ($15,000 +)

Patron ($10,000-$14,999)

Sponsor ($5,000-$9,999)

Partner ($1,500-$4,999)

Friend ($500-$1,499)

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An invoice for your annual dues contribution will be provided to facilitate processing.

Billing Questions: Please contact Tom Leach at tom@psbr.org or 717-731-3557

Please provide additional key contacts that should be included on relevant PSBR email communications.

1.) External Communications/Public Relations Name

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1a.) External Communications/Public Relations Email

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2.) Government/State Relations Name

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2a.) Government/State Relations Email

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3.) Internal Communications/Internal Affairs Name

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3a.) Internal Communications/Internal Affairs Email

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4.) Legal Affairs Name

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4a.) Legal Affairs Email

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5.) Security Name

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5a.) Security Email

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6.) Other Contact (Title/Name)

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6a.) Other Email

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All applications for membership in the Pennsylvania Society for Biomedical Research (PSBR) are subject to review and approval by the Board of Directors, which may be approved or declined for any reason in the Board of Director's sole discretion. Membership may be revoked at anytime, upon the recommendation and two-thirds vote of the Board of Directors, for any reason in the Board's sole discretion. Members shall not use the name, logo, or other symbols of PSBR for any advertising, marketing, policy making, or promotional purposes without the prior written consent of PSBR. Thank you!