DATIA Membership Renewal Form


Part 1: Company Information

Company Name
Member Number	(if you have it from your renewal notice)
Primary Contact Name
Primary Contact's Email
Address
City
State/Province
Country
Zip
Phone
Fax
Website

Note: Fields in red are required values

Part 2: Membership Categories

Below, please find an outline of the benefits associated with each membership level. While you are to join at the minimum level based on the size of your organization, feel free to join at a higher level to take advantage of increased benefits.
Member Benefits Overview
Receive quarterly DATIA focus Magazine Receive weekly DATIA eNews Receive full access to information on datia.org Are listed on the Searchable Internet Drug & Alcohol Testing Industry Directory and Buyers' Guide Recieve Washington Representation and regulatory alerts Have full voting privileges on association matters Have the opportunity to be elected to serve on the association's Board of Directors Can attend DATIA networking events and legislative and regulatory briefings at member rates Receive discounts on publications, annual conferences and training sessions

Membership Categories (please choose one)

Regular (1-5 employees) ($249) - All benefits in above overview plus:

Searchable Internet Drug & Alcohol Testing Industry Directory and Buyers' Guide Listing in a total of three categories

Corporate (6+ employees) ($500) - All benefits in above overview plus:

Searchable Internet Drug & Alcohol Testing Industry Directory and Buyers' Guide Listing in a total of eight categories for up to five company locations
Ability to have up to five company representatives individually receive DATIA focus and other pertinent mailings
One complimentary set of DATIA Membership Mailing Labels for use in marketing, and the opportunity to purchase additional sets

Sustaining Corporate ($1900) - All benefits in above overview plus:

Searchable Internet Drug & Alcohol Testing Industry Directory and Buyers' Guide Listing in an unlimited number of categories for an unlimited number of company sites
Ability to have up to 10 company representatives individually receive DATIA focus and other pertinent mailings
Listing of company on DATIA letterhead
Prominent listing on the DATIA website with a link to company's website
Two complimentary sets of DATIA Membership Mailing Labels for use in marketing, and the opportunity to purchase additional sets
20% discount on conference sponsorship with preferred booth location
One complimentary registration to the DATIA Annual Conference

Part 3: Promotional Categories for Industry Directory

Please check the categories under which you would like your company's listing to appear. Regular Membership (1-5 employees) includes three (3) complimentary categories Corporate Membership (6+ employees) includes eight (8) complimentary categories Sustaining Membership includes unlimited complimentary category listings Additional category listings can be purchased for $15 per category.
Service Categories
Alcohol Testing	Certified Breath Alcohol Technician	Alternative Specimen Testing
Background Screening	Collection Services	Consortium/TPA
Consultant	DOT Physicals	DNA Testing
Drug Free Policy Development	EAP	Freelance Specimen Collection
Laboratory	Medical Review Officer	Mobile Collections
Non-mandated Testing	On-Site Testing	Q A Services
Student Drug Testing	Substance Abuse Counseling/Treatment	Substance Abuse Professional (SAP)
Supervisor/Employee Training	24 hour availablity	Franchise & Business Opportunities
Supplier Categories
Alcohol Testing Instruments	Collection Supplies	Drug Testing Supplies
Alcohol Testing Kits	Periodicals	On-Site Drug Testing Kits
Alcohol Testing Supplies	Testing Software	Training Supplies
Agency and Modes Tested
FAA FMCSA FRA FTA PHMSA USCG DOD DOE NASA NRC
Promotional 50 Word Listing
Increase the effectiveness of your listing by including a 50-word description of your company's products and/or services. The description will be included in all categories under which your company appears. This feature is available for $50. This description is complimentary for Sustaining Members. (No descriptions beyond 50 words will be accepted)

Bolding
YES! Please print my listing in Bold Print.

Part 4: 2009-2010 Dues

	2009-10 Membership Dues	Category Listings*	50 Word Description	Bold Print Listing	Total
	Regular (1-5 employees) $249	=
	Corporate (6+ employees) $500	=
	Sustaining $1900	no charge	no charge	no charge
*Optional Additional DATIA focus* Subscriptions**
	Annual Subscription - $48	=
				TOTAL
	*(regular includes 3 categories, corporate 8, sustaining unlimited)

Part 5: Payment Information
Payment Type:	MC VISA AMEX
Cardholder's Name	Card #
Exp. Date
This online registration form is secured utilizing the highest level of encryption security possible. This means you can rest assured that communications (e.g. credit card numbers) between your browser and this site's web servers are private and secure.
This is a secure order form but if you prefer to print this out our Fax is: (202) 315-3579 For Check payments please print this out and send to: DATIA • 1325 G Street, NW, Suite 500#5001 Washington, DC 20005

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