New
Renewal Date: ______________
I N D U S T R Y M E M B E R S H I P A P P L I C AT I O N
LOS ANGELES
COMPANY INFORMATION Company Name ____________________________________________________
INDUSTRY SEGMENT & MARKET FOCUS CATEGORY ❒ Academic
❒ Non-Profit
❒ Government Agency
❒ Private Company
Address ____________________________________________________________
❒ Research Institute
❒ Public Company
City_________________________________ State _________ Zip ___________
PRIMARY TECHNOLOGY (Check One)
Phone _____________________________________________________________
❒ Aquaculture
❒ Drug Delivery
❒ Proteomics
❒ Bioinformatics
❒ Drug Development
❒ Stem Cell Research
# of Employees in California ________
❒ Biomanufacturing
❒ Epigenomics
❒ Therapeutics
# of Employees Worldwide _________
❒ Biorenewables
❒ Functional Genetics
(majority are biologics)
❒ Biosimilars
❒ Gene / Cell Therapy
❒ Therapeutics
❒ Cell Biology
❒ Genetics / Genomics
(majority are small
❒ Clinical Research
❒ Micro Arrays
molecules)
❒ Contract
❒ Microfluidics
❒ Research Tools
Manufacturer
❒ Molecular
(products support
❒ Contract Research
Diagnostics
discovery and R&D)
❒ Devices
❒ Nanotechnology
❒ Vaccines
❒ Diagnostics
❒ Platform
❒ Wearable Sensors
❒ Digital Health
Technologies
Company Website ___________________________________________________
Private ❒ Public ❒ Ticker Symbol ___________ Are you a virtual company? Yes ❒ No ❒ Do you have a lab? Yes ❒ No ❒ Do you have a cleanroom? Yes ❒ No ❒ Your fiscal year starts _____________
PRIMARY CONTACTS STAGE OF DEVELOPMENT
PRIMARY CONTACT(Responsibilities include receipt of all official correspondence, designation of company personnel to serve on Biocom committees and updates of company information)
______________________________________________________________________________ Name & Title Email Phone
ALTERNATE CONTACT
primary contact is unavailable)
(Responsibilities include receipt of all official correspondences if
______________________________________________________________________________ Name & Title Email Phone
BILLING CONTACT membership dues)
(Responsibilities include receipt of membership invoice and payment of
______________________________________________________________________________ Name & Title Email Phone
SECONDARY BILLING CONTACT (Responsibilities include receipt of membership
invoice and payment of membership dues if primary billing contact is unavailable)
______________________________________________________________________________ Name & Title Email Phone
PURCHASING CONTACT (Responsibilities include receipt of all official correspondence from Biocom Purchasing Group and Purchasing Group preferred suppliers) ______________________________________________________________________________ Name & Title Email Phone
❒ Preclinical / Research
❒ Phase II
❒ Phase IV
❒ Phase I
❒ Phase III
❒ On Market
HEALTHCARE FOCUS (Check all that apply) ❒ Allergy
❒ Food & Agriculture
❒ Pain Management
❒ Aquaculture
❒ Functional Genetics
❒ Personal Care
❒ Automimmune Disease
❒ Gastroentorology
❒ Platform Technologies
❒ Biodefense
❒ Gene / Cell Therapy
❒ Precision Medicine
❒ Bioinformatics
❒ Genetic Disorders
❒ Proteomics
❒ Biomanufacturing
❒ Genetics / Genomics
❒ Pulmonary
❒ Biorenewables
❒ Hematology
❒ Regenerative Medicine
❒ Biosimilars
❒ Immunology
❒ Renal
❒ Cardiovascular
❒ Immunotherapy
❒ Reproductive Medicine
❒ Cell Biology
❒ Infectious Diseases
❒ Research Tools
❒ Central Nervous System
❒ Inflammatory Diseases
(products support
❒ Chemicals
❒ Mental Health
discovery and R&D)
❒ Clinical Research
❒ Metabolic
❒ Respiratory
❒ Contract Manufacturer
❒ Micro Arrays
❒ Stem Cell Research
❒ Contract Research
❒ Microfluidics
❒ Therapeutics (majority
❒ Dermatology
❒ Molecular Diagnostics
are biologics)
❒ Devices
❒ Musculoskeletal
❒ Therapeutics (majority
❒ Diagnostics
❒ Nanotechnology
are small molecules)
❒ Digital Health
❒ Neurology
❒ Tissue Engineering
❒ Drug Delivery
❒ Nutraceuticals
❒ Urology
❒ Drug Development
❒ Oncology
❒ Vaccines
❒ Endocrinology
❒ Opthamology
❒ Wearable Sensors
❒ Epigenomics
❒ Orphan / Rare Diseases
COMPANY CONTACTS CEO/ President _____________________________________________________
Human Resources ___________________________________________________
Email _________________________________ Phone ____________________
Email _________________________________ Phone ____________________
CEO Assistant _____________________________________________________
Government Affairs _________________________________________________
Email _________________________________ Phone ____________________
Email _________________________________ Phone ____________________
CFO ______________________________________________________________
Marketing _________________________________________________________
Email _________________________________ Phone ____________________
Email _________________________________ Phone ____________________
CSO/CMO __________________________________________________________
Business Development _______________________________________________
Email _________________________________ Phone ____________________
Email _________________________________ Phone ____________________
Director of R&D ____________________________________________________ Email _________________________________ Phone ____________________
MEMBERSHIP CATEGORIES
Life Science Industry Membership Level/ Annual Dues (check one) ❒ 500+ employees .............................. ❒ $30,000
PREMIUM ❒ $35,500
Non-Profit Membership Level (check one) Research Institutions: ❒ more than 26 employees............................ ❒ $3,200
PREMIUM ❒ $8,700
❒ 251 - 499 employees ....................... ❒ $24,500
❒ $30,000
❒ 201 - 250 employees ....................... ❒ $18,000
❒ $23,500
❒ less than 25 employees.............................. ❒ $2,200
❒ $7,700
❒ 151 - 200 employees ....................... ❒ $17,000
❒ $22,500
❒ Trade Associations .................................... ❒ $1,700
❒ $7,200
❒ 101 – 150 employees........................ ❒ $15,000
❒ $20,500
❒ Academic Institutions ............................... ❒ $1,700
❒ $7,200
❒ 51-100 employees............................. ❒ $9,600
❒ $15,100
❒ Other ......................................................
❒ $2,700
❒ $8,200
❒ 26-50 employees............................... ❒ $7,200
❒ $12,700
❒ 11-25 employees............................... ❒ $3,700
❒ $9,200
❒ 4-10 employees................................. ❒ $1,600
❒ $7,100
❒ 1-3 employees................................... ❒ $1,000
❒ $6,500
Premium Membership offers you maximum exposure opportunities and access to exclusive events in the life science community.
PAYMENT (Full payment must accompany this form. Dues are valid for one year.) I ______________________, on behalf of ________________________ (hereafter “company”) affirm that company’s membership will automatically renew and be considered due annually upon company’s anniversary date. Membership cancellations must be received in writing prior to your renewal date via email to the membership department at membership@biocom.org.
Dues Amount: $____________________________________
Signature_______________________________________________________ Title ______________________________ Date _______________________
Exp. Date_________________
*Biocom reserves the right to cancel membership at any time. Biocom membership dues are non-refundable in whole or in part for any reason.
❒ Check Enclosed (please make checks payable to Biocom) ❒ Credit Card Payment: ❒ AMEX
❒ VISA
❒ MC
Credit Card # _________________________________________________ Name on Credit Card__________________________________________ CSC (3-digit or 4-digit code)______________
Signature _____________________________________________________
Please mail completed form to: Biocom Membership Department 10996 Torreyana Rd, Suite 200, San Diego, CA 92121 P: 858.455.0300, kjenkins@biocom.org
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