Southern California Biomedical Council Membership Renewal Application

Completed By:__________________________________ Date:_____/_____/_________

Company Information (This information will appear on our website)

___________________________________ Company Name

____________________________ Phone □ HQ

□ Lab ___________________________________ Address

____________________________ Fax □ Mfg.

___________________________________ City, State, Zip

____________________________ Website

□ Office

___________________________________ Chairman, Pres./CEO

____________________________ Phone

___________________________________ Email

____________________________ Fax

Check all that apply

Other Company Officers (Name, phone, & email)

COO: __________________ CSO: __________________ CMO: __________________ CFO: __________________

__________________ __________________ __________________ __________________

__________________ __________________ __________________ __________________

Regulatory: __________________ Manufacturing/ Engineering: __________________ Purchasing: __________________

__________________ __________________ __________________

__________________ __________________ __________________

Membership Classification (Please choose ONE) Core Member Allied Industries and Services Non-profit

Please check one primary business focus Please check one primary business focus Please check one primary business focus

Agbiol/Industrial Biotech Bioinformatics Contract Research & Manufacturing Drug Development Medical Device Research Products & Instrumentation Human Diagnostics Digital Health/Telemedicine

Business & Financial Consulting Investment & Capital Firms Information Technology Insurance Human Resources & Staffing Law Firms Marketing/Communication Packaging/Delivery Real Estate & Property Regulatory/Clinical/Product Development Publications Cleanroom Operations & Mechanics

Academic Foreign Agencies Government Hospitals Non-Profit Organization Non-Profit Research Institute Healthcare Providers

Membership Type/Company Interest COMMITTEE INTEREST Communications/Advocacy Land Use/Facility Planning Women Work & Wisdom (W3) Manufacturing/Engineering/Regulatory Membership Purchasing Group Annual SoCalBio Conference Education/Workforce Business Support Roundtables SoCalBio Holiday Dinner and Award CeremonyAREAS OF SPONSORSHIP INTEREST Annual SoCalBio Conference Annual Members' Meeting SoCalBio Networking Forum Best Practice Regulatory/Engineering/Facility Planning Workshops Workforce Summit Sub-regional Business Support/Tech. Development Roundtables Publication: SoCalBio Weekly Update Publication: Directory of life-science firms in Greater Los Angeles SoCalBio Holiday Dinner and Award Ceremony Annual Workshop on Government Funding

No. of Employees in CA: _______

Membership Type/Company Interest (Cont.) MEMBERSHIP TYPE/ANNUAL DUES (check what is applicable) Non-profit Organization: Academic/Research Institution $750Government/Development Agency $750Trade Association $750Other Non-Profit $750

Biomed/Biotech Companies: With 20 or Fewer Full-time So. Cal. Employees $500With Between 21 - 50 Full-time So. Cal. Employees $750With Between 51 - 100 Full-time So. Cal. Employees $1,000More Than 100 Full-time So. Cal. Employees (with no revenues from sales) $2,000 More Than 100 Full-time So. Cal. Employees (with revenues from sales) $4,000

Providers of Allied Products and Services: Sole Proprietorship $500With 6 - 15 Full-time So. Cal. Employees $750With Between 16 – 30 Full-time So. Cal. Employees $1,000With Between 31 - 60 Full-time So. Cal. Employees $2,000 With Between 61 - 100 Full-time So. Cal. Employees $3,000With More Than 100 Full-time So. Cal. Employees $5,000

Payment Information DUES POLICY: Full payment must accompany this form. Dues are valid for one year. (check one) Check Enclosed (Make checks payable to the Southern California Biomedical Council)

Credit Card (check one):

Credit Card #: ...........................................................…………………………….………………………………CVS #: …………………Expiration Date (MM/YY): ....................................................................................................................................... Name of Card Holder: ............................................................................................................................................. Billing Address: ....................................................................................................................................................... Signature: ...............................................................................................................................................................

Date Member Effective _____________________ (for office use only)

Group Purchasing Options Make sure to take advantage of the SoCalBio Group Purchasing Program offered in collaboration with BIO and made available to members of the Southern California Biomedical Council. This program will enable you to enjoy discounts and special benefits on products and services that are essential to your business operations. For details, see: http://socalbio.org/wordpress/group-purchasing

Please indicate which SoCalBio group purchasing vendor is of interest to you:

About SoCalBio

SoCalBio is a trade association serving the biotech, biopharma, medtech, diagnostics and digital health industries in Los Angeles, Orange County, Inland Empire, and the communities of the Gold Coast of California in Ventura and Santa Barbara Counties. Our mission is to create and nurture a viable eco-system to grow and retain bioscience companies for economic growth and job creation in Southern California. See more info at: http://www.socalbio.org

SoCalBio is a C(6) non-profit corporation. Tax ID: 95-4555008 617 S. Olive St., Ste. 700, Los Angeles, CA 90014 Phone: 800-418-7079 ext 3 Fax: 213-403-7688

E-mail: scbc@socalbio.org

Member Representative: (The primary contact across all departments regarding SoCalBio membership.)

________________________ Name

________________________ Phone

________________________ Title

________________________ Email

________________________ Address (If different)

________________________ City, State, Zip

Invoice Contact: (Receives important documents regarding dues and renewal)

________________________ Name

________________________ Phone

________________________ Title

________________________ Email

________________________ Address (If different)

________________________ City, State, Zip

□ VWR (Lab Equipment & Supplies) □ Clean Harbor (Hazardous Waste Disposal)□ Airgas (Medical & Industrial Gases)□ UniFirst (Workwear Services)□ UniClean (Cleanroom Services)

□ Office Depot (Office Supplies)□ Chubb/Bolton & Company (Business Insurance)□ AON/Bolton & Company (D&O LiabilityInsurance) □ UPS (Shipping Services)□ ALT (Pre-owned & Refurbished Lab Equipment□ Scientist.com (R&D Service Sourcing)

□ Share Vault (Secure Document)□ Business Wire (News Distribution)□ Corporate Travelers (Corporate Travel Services)□ Humboldt (Moving & Storage)□ Trinet (HR Solution)