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 $25,000
Principal PLUS Member* - US $18,000
Principal 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 Alliance

Consent*

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 Payment

Check
Credit Card* (Accept Visa, Mastercard, American Express, Discover, JCB)
Wire Transfer*

Make checks payable to “The Secure Technology Alliance,” and mail to: Secure Technology Alliance, 4680 S. Downing St. Englewood, CO 80113. (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 Details

Organization Name*

Website*

Address*

Please provide logo

If available (allowed file types: jpg, gif, png, pdf).

Accepted file types: jpg, gif, png, pdf, Max. file size: 700 MB.

Primary Member Point of Contact

(for official letters and renewal notices and/or payments)

Name*

First Last

Title*

Email*

Phone*

Fax

Organization Type*

Primary Service Offered*

Provide short description of company*

Permission to include company name on membership lists for general marketing purposes*

Yes
No

Permission to provide link from U.S. Payments Forum site to your organization's website*

Yes
No

If 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 applicable

Name

First Last

Company

Additional 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 activities

List

Name	Title	Email

If you have any questions or issues while filling out the form please email Jason Bohrer: [email protected].

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Email

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Membership Application

Membership Application

Organization Details

Primary Member Point of Contact

Please list the referring U.S. Payments Forum member that led you to join, if applicable

Additional Contact Names (other than the Primary Contact)

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