For SMART Membership questions, contact Bob Carullo at 609-304-2904 or bcarullo@smartstates.com
ANNUAL MEMBERSHIP APPLICATION
Level of Membership (Please check one or delete others) Date:
Business
Large Business (501 + employees) $5,000.00
Small Business (201 to 500 employees) $1,000.00
Small Business (11 to 200 employees) $500.00
Micro Small Business(1-10 employees) $200.00
Academia and Gov’t Labs/Field Agencies
Universities and Federal Labs/Agencies $1,000.00
Colleges and State Agencies $500.00
Schools and Local Gov’t $250.00
Annual period is from date of application; contact Bob Carullo for membership questions at 609-304-2904 or bcarullo@smartstates.com If an invoice is needed, contact Bob. Please copy and paste this completed form in an e-mail to pamifillion@comcast.net
To pay by check, please make check payable to SMART and mail to:
Pamela Fillion, SMART Treasurer
17 Crested Butte Court
Shamong, NJ 08088-8227
If paying by credit card, complete below and mail to above or e-mail; we complete a credit card transaction for the amount listed above:
a. Card Type (AMEX, VISA, etc):
b. Full Name on Card:
c. Account Number:
d. Expiration Date:
e. Security Code:
f. Billing Address:
Company Name:
Number of Employees:
Website:
Mailing Address:
Contact Name:
e-mail:
Phone: Fax: