Membership Application Completing this application form serves as a letter of intent by the organization listed above to join the U.S. Payments Forum, a cross-industry body that addresses a variety of payments technologies that protect the security of, and enhance opportunities for payment transactions within the U.S. The U.S. Payments Forum bylaws define seven membership categories. Select the appropriate membership level you intend to join. Please carefully review the benefits and any restrictions associated with each level. Please carefully review the membership levels and each level’s benefits and any restrictions associated with each level.Select Membership Level*(Current Secure Technology Alliance members receive 20% discount on Principal Memberships and below.)Global Payments Network - US $25,000Principal PLUS Member* - US $18,000Principal Member - US $12,000 (US $9,600 for Secure Technology Alliance members)General Member - US $5,000 (US $4,000 for Secure Technology Alliance members)Industry Association Member - US $1,750 (US $1,400 for Secure Technology Alliance members)Government Member - US $1,750 (US $1,400 for Secure Technology Alliance members)Associate Member - US $1,200 (US $960 for Secure Technology Alliance members)* This level of membership in the Forum includes privileges in the Secure Technology AllianceConsent* I acknowledge that I have read the U.S. Payments Forum bylaws, meet the qualifications for the membership level selected, and agree to the terms and conditions of the U.S. Payments Forum.*U.S. Payments Forum membership runs for one year, beginning with the first day of the month that the application is received. This membership expires one year after the start date of this membership. The applying member intends to join the U.S. Payments Forum at the membership level indicated above and agrees to the payment of the annual membership fee. Payment terms are (30) days from the date of signing this application.Method of PaymentCheckCredit Card* (Accept Visa, Mastercard, American Express, Discover, JCB)Wire Transfer*Make checks payable to “The Secure Technology Alliance,” and mail to: Secure Technology Alliance, 191 Clarksville Road, Princeton Junction, NJ 08550. (the U.S. Payments Forum shares a banking and membership administrator relationship with the Secure Technology Alliance) * If paying by credit card or wire transfer, our membership administrator will email the Point of Contact with details on how to complete your payment.Organization DetailsOrganization Name*Website*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Please provide logoIf available (allowed file types: jpg, gif, png, pdf).Accepted file types: jpg, gif, png, pdf.Primary Member Point of Contact(for official letters and renewal notices and/or payments)Name* First Last Title*Email* Phone*FaxOrganization Type*Acquirer/ProcessorAssociationConsult/IntegratorGlobal BrandsGovernmentIndustry SupplierIssuerMerchant/RetailerMobile PaymentRegional Debit NetworkPrimary Service Offered*CardsDevicesTerminalsCard IssuanceServicesPayments ApplicationsProvide short description of company*Permission to include company name on membership lists for general marketing purposes*YesNoPermission to provide link from U.S. Payments Forum site to your organization's website*YesNoIf yes, please provide exact URL to link to your website*Please list the referring U.S. Payments Forum member that led you to join, if applicableName First Last CompanyAdditional Contact Names (other than the Primary Contact)Representing your company to receive communications like newsletters and invitations to U.S. Payments Forum programs, events, and other member activitiesListNameTitleEmail If you have any questions or issues while filling out the form please email Randy Vanderhoof: [email protected].CAPTCHAEmailThis field is for validation purposes and should be left unchanged. 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