ATIA Membership Application

Member Directory Profile Information

This information will be displayed on the online searchable Member Directory that is available to the public. ATIA's membership year is from January 1st - December 31st.

Company Name*

Street Address*

Street Address Line 2

City*

State/Province

Other State/Province

If your state or province isn't listed in the dropdown above.

Zip/Postal Code*

Country*

Main Company Phone Number*

800 Number

General Company E-mail Address*

Website*

Company Logo*

Upload company logo to be displayed in Directory. (File formats .jpeg and .png are accepted.)

Accepted file types: jpg, jpeg, png, Max. file size: 3 MB.

Company Description*

Enter a description to be displayed in Directory.

Company Technology and Business Areas of Focus for Directory search options. Please select all that apply.

Disability*

Blindness
Cognitive
Communication
Deaf/Hard of Hearing
Learning
Low Vision
Mobility
Physical
Other

Other Disabilities

Please enter as a comma-separated list.

Age / Population*

Early childhood
School
Higher education
Post-Secondary
Adult
Senior / Aging
Other

Other Ages / Populations

Please enter as a comma-separated list.

Environment*

Other Environments

Please enter as a comma-separated list.

Contact Information

This information will not be displayed in the public Member Directory. Contact information will be used for communications on member topics such as renewal, news and other member programs.

Primary Contact Information

The Primary Contact is responsible for member renewal.

First Name*

Last Name*

Title*

Email*

Your email address will be your username.

Password*

Enter Password Confirm Password

Phone Number*

Contacts

CEO/President or similar role

First Name*

Last Name*

Title*

Email*

Phone Number*

VP/ Director Sales or similar role

First Name

Last Name

Title

Email

Phone Number

VP/ Director Marketing or similar role

First Name

Last Name

Title

Email

Phone Number

VP/ Director Training or similar role

First Name

Last Name

Title

Email

Phone Number

Events Manager/ Coordinator or similar role

First Name

Last Name

Title

Email

Phone Number

Do you have policy contacts?

Yes
No

Policy Contact 1 First Name

Policy Contact 1 Last Name

Policy Contact 1 Title

Policy Contact 1 Email

Policy Contact 2 First Name

Policy Contact 2 Last Name

Policy Contact 2 Title

Policy Contact 2 Email

Policy Contact 3 First Name

Policy Contact 3 Last Name

Policy Contact 3 Title

Policy Contact 3 Email

How did you hear about ATIA?

Conference
ATIA Staff
Web site
Email
ATIA Member

If you were referred by an ATIA Member, please provide us with more details to we can pass on a referral thank you reward.

Referral Contact Name

Referral Company Name

Comments / Notes

Membership Options*

Small Company Regular Membership - Annual Revenues under $500K - $650
Regular Membership - Annual Revenues of $500K - $99M - $1,250
Regular Global Membership - Annual Revenues over $99M - $4,600
Associate Distributor * - $200

* Members at the Associate level do not carry association voting privileges and are ineligible to serve as Board Directors.

Premier Listing

Upgrade my listing to a premier listing

Premier listing positions your company listing at the top of the member directory attractively highlighted as a boxed listing. Learn more.

Promotion Code

Payment Information

Please note that if you are using a payment method other than credit card, you will receive instructions via e-mail on how to submit payment and your membership will not be approved until payment has been received. For any questions on the status of your membership application, please contact membership@atia.org.

Payment Method

Credit Card
International Wire Transfer/ACH

Credit Card

American Express

Discover

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Total

$0.00