Membership Application | Service Organization Step One Step Two Step Three: Confirmation Fill Out Your Application | Service Organization Please fill out the following form if you are interested in becoming a member of the Food and Drug Law Institute. All fields are required unless otherwise indicated. Questions? [email protected]202-222-0910Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 2Membership Type *ManufacturerContract Manufacturer, Supplier, or DistributorLaw FirmConsultingPublic Health/Patient OrganizationAssociation Organization/Company InformationOrganization/Company Name *Organization AddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZipProvince/Region/Country *Organization Website *Manufacturer Revenue: Choose the range that best reflects your company's revenue resulting from manufacture of FDA-or USDA-regulated products in the prior year. *Start-up Manufacturer (no sales)Sales less than $100 millionSales $100 - $500 millionSales $500 million - $1 billionSales $1 - $10 billionSales more than $10 billionContract Manufacturer Revenue: Choose the range that best reflects your company's revenue resulting from manufacture of FDA-or USDA-regulated products in the prior year. *Sales less than $100 millionSales $100 – $500 millionSales $500 million – $1 billionSales more than $1 billionPrimary ContactPrimary Contact is typically a partner or a senior-level individual, and is FDLI’s first point of contact for substantive or programmatic issues and will be copied on emails regarding their organization/company. This individual receives their organization/company’s complimentary Food and Drug Law Journal subscription, though there is an option for it to be sent to an alternative colleague. Name *FirstLastJob Title * Phone *Email *LinkedIn (Optional)Primary Contact Address *Same as organization's addressAdd addressSelect "Same as organization's address" or "Add address"City *State/Province/Region *Postal Code *Country *Primary Contact's AssistantAssistant's NameFirstLastAssistant's EmailNextBilling Contact InformationThe billing contact is one of FDLI’s main contacts during the initial membership payment procedure and during the membership renewal process. The billing contact will be sent the membership invoices and will be sent emails regarding membership expiration, renewal, and payment.Billing Contact *Send invoice to primary contactAdd contactName *FirstLastJob Title *Phone *Email *LinkedIn (optional)Membership InterestsAre there FDLI member benefits that are of particular interest to you? (optional)Any other comments? (optional)How did you hear about us? (optional)Acknowledgment *I certify that the information above is true to the best of my knowledge and understand that my application is subject to review by FDLI.Submit admin2023-02-14T09:53:30-05:00
