animlinclogo.gif (15703 bytes)Life Science Industry Council

 



Advancing Life Science Companies Through Education and Networking
 

 

Membership Information

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Programs
Events
Board Members
Related Sites
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For more information on
LINC's Membership Opportunities
please contact
:


LINC Office
(949) 830-9338
admin@elinc.org

Membership Information and Application:

Click Here for an Application


Membership Application

Membership Fees Classification: (Based on Number of Employees)
Please check one of the boxes below

1-5                    $250
6-50                  $500   
51-100             $1000
101 +                $1500
Individual Academic/Researcher    $35

Contact Information:

Contact Person
Company
Address
City
State
Zip
Phone
Fax
Email

Additional Company Representatives: 

Name:     Title:
Fax:     E-mail:
Name:     Title:
Fax:     E-mail:
Name:     Title:
Fax:    E-mail:
Name:     Title:
Fax:     E-mail:
Name:     Title:
Fax:     E-mail:
Name:     Title:
Fax:     E-mail:

Company Profile:
Date Founded: 
Annual Revenue: 
Public/Private: 
Product(s)/Service(s): 
Number of Employees: 
Number of Locations: 

How would you classify your company:
(Please check off any of the following that apply)
Bio-Medical                              BioTechnology
Contract R&D                           Contract Manufacturing
Health Care Provider                 Manufacturing
Medical Date/Software              Medical Device
Medical Diagnostic                    Medical Manufacturing
OEM                                         Pharmaceutical
Health Services                          Architectural
Financial (type):       Public Relations
Legal (type):         Real Estate       

Method of Payment:
Check No.:   Amount Paid:  
Visa                        Master Card                    American Express
Name on Credit Card: 

Credit Card Number: 
Expiration Date:  
Signature:  

Please make checks payable to:  Life Science Industry Council
25283 Cabot Road, Suite 112 Laguna Hills, CA  92653

PRINT THIS FORM AND FAX TO: (949) 830-9515

 

 

 

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