The BioTech Forum

To apply for Membership for The Biotech Forum, please review and complete the following application below and submit a one-page biography. The Biotech Forum has a strict confidentiality policy and will not disclose any of the personal information you have provided herein.

The Biotech Forum Membership Application

Membership Dues

The annual Membership Dues for The Biotech Forum are $395 per person. If your membership in the group is not approved by The Biotech Forum Membership Committee, your membership fee will be refunded to you.

Confidentiality Policy

The Biotech Forum has a strict confidentiality policy and will not disclose any of the personal information you have provided herein.

No Solicitation Policy

The Biotech Forum was formed for the purpose of providing a trusted environment for scientists, investors, entrepreneurs and government representatives to come together to exchange knowledge, resources and relationships in order to create a vibrant biotech hub along the 101 corridor. As a result, the Forum enforces a strict “no solicitation” policy and you hereby agree that you will not solicit Forum members with consulting or other services unless specifically requested. The Forum reserves the right to rescind the membership status of any member who does not abide by this policy.

All fields in bold are required.

Contact Information

First Name
Last Name
Job Title
Company Name
Business Address 1
Business Address 2
City
State
Zip Code
Phone Number
Fax Number
Email Address
Web Site
Referred By

Personal Information

Home Address 1
Home Address 2
Home Phone
Date of Birth
Marital Status
If Married, please provide your spouses name

Educational Background

Degree	Area of Study	School	Years Attended

Employment History

Current Employer
Position/Duties
Name of Company
Nature of Business
Years Employed

Past Employer
Position/Duties
Name of Company
Nature of Business
Years Employed

Previous Positions Held:

Personal and Professional Interests

What personal or professional expertise or skills do you have which you are willing to share for the benefit our membership? Please describe:

What is your reason for joining The Biotech Forum?

Are you willing to serve on one or more of the following Biotech Forum Committees? Please check below:

	Education Committee (Plans educational and business networking events and symposiums)
	Website Committee (Provides content for Biotech Forum website)
	Social Committee (Plans and coordinates Forum social events)
	Membership Committee (Interviews and selects members from pool of Forum applicants)

What are your particular hobbies or interests? Please describe:

Your Biography

	Copy and paste your 1- page Biography for submission. (Text submission only, does not support graphics
	E-mail a 1-page Word or PDF file of your Biography to the e-mail address provided on the next page.

Copy and paste your one-page Biography into the box below:

Please enter the code displayed in the image below:

Please remember to review your complete form submission for accuracy. A copy of your form application will be e-mailed to the address you provided above.

Thank you for applying to become a member of The Biotech Forum.